Healthcare Provider Details

I. General information

NPI: 1821123803
Provider Name (Legal Business Name): JASON RUNYAN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13927 SHIPWRECK CIR N
JACKSONVILLE FL
32224-1121
US

IV. Provider business mailing address

13927 SHIPWRECK CIR N
JACKSONVILLE FL
32224-1121
US

V. Phone/Fax

Practice location:
  • Phone: 904-570-9404
  • Fax: 904-379-9332
Mailing address:
  • Phone: 904-570-9404
  • Fax: 904-379-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9334592
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4425P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: