Healthcare Provider Details

I. General information

NPI: 1407919087
Provider Name (Legal Business Name): SEA OATS MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 AIRPORT RD STE C & D
PANAMA CITY FL
32405-4030
US

IV. Provider business mailing address

508 AIRPORT RD STE C & D
PANAMA CITY FL
32405-4030
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-8624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2654
License Number StateFL

VIII. Authorized Official

Name: JAMES D DEAS
Title or Position: PAC
Credential:
Phone: 850-769-8624