Healthcare Provider Details

I. General information

NPI: 1497880348
Provider Name (Legal Business Name): WILLIAM S LAX PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 LANE AVE S
JACKSONVILLE FL
32205-4785
US

IV. Provider business mailing address

PO BOX 80883
ATHENS GA
30608-0883
US

V. Phone/Fax

Practice location:
  • Phone: 904-783-9680
  • Fax: 904-783-9680
Mailing address:
  • Phone: 706-549-8114
  • Fax: 706-549-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3350
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: