Healthcare Provider Details

I. General information

NPI: 1770574337
Provider Name (Legal Business Name): FRANK GRIMALDI JR. PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SHIRCLIFF WAY SUITE 300
JACKSONVILLE FL
32204-4753
US

IV. Provider business mailing address

1325 SAN MARCO BLVD SUITE 701
JACKSONVILLE FL
32207-8568
US

V. Phone/Fax

Practice location:
  • Phone: 904-388-1400
  • Fax: 904-388-9644
Mailing address:
  • Phone: 904-346-3465
  • Fax: 904-858-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103279
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: