Healthcare Provider Details

I. General information

NPI: 1265445092
Provider Name (Legal Business Name): WAYNE MCCUTCHEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 PENSACOLA BLVD
PENSACOLA FL
32505-1705
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-2000
  • Fax:
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: