Healthcare Provider Details

I. General information

NPI: 1710388244
Provider Name (Legal Business Name): MORGAN PARKS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BARTRAM OAKS WALK SUITE 104
JACKSONVILLE FL
32259-3243
US

IV. Provider business mailing address

115 BARTRAM OAKS WALK SUITE 104
JACKSONVILLE FL
32259-3243
US

V. Phone/Fax

Practice location:
  • Phone: 904-240-0442
  • Fax: 904-240-0471
Mailing address:
  • Phone: 904-240-0442
  • Fax: 904-240-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9108138
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: