Healthcare Provider Details

I. General information

NPI: 1912619297
Provider Name (Legal Business Name): SIERRA MAGUIRE LARSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

PO BOX 13834
TALLAHASSEE FL
32317-3834
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: