Healthcare Provider Details

I. General information

NPI: 1679986129
Provider Name (Legal Business Name): PETER MASTERSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 KINGSLEY AVE STE 300
ORANGE PARK FL
32073-4898
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-0643
  • Fax: 904-621-0644
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-619-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9238188
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: