Healthcare Provider Details

I. General information

NPI: 1497021059
Provider Name (Legal Business Name): RALPH DAVID PRIDDY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 STATE ROAD 207
ST AUGUSTINE FL
32086-9329
US

IV. Provider business mailing address

3612 CITARA CT
ST AUGUSTINE FL
32092-4779
US

V. Phone/Fax

Practice location:
  • Phone: 904-827-8610
  • Fax:
Mailing address:
  • Phone: 904-814-6703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106486
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: