Healthcare Provider Details

I. General information

NPI: 1922831585
Provider Name (Legal Business Name): ANDREA DZIWULSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 BEACH BLVD
JACKSONVILLE FL
32216-2820
US

IV. Provider business mailing address

2025 COUNTY ROAD 209B
GREEN COVE SPRINGS FL
32043-5103
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: