Healthcare Provider Details

I. General information

NPI: 1871686352
Provider Name (Legal Business Name): PHILLIP ALEX WIMPELBERG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 US HIGHWAY 1 S STE B
ST AUGUSTINE FL
32086-6301
US

IV. Provider business mailing address

2720 US HIGHWAY 1 S STE B
ST AUGUSTINE FL
32086-6301
US

V. Phone/Fax

Practice location:
  • Phone: 904-827-0078
  • Fax: 904-827-0140
Mailing address:
  • Phone: 904-827-0078
  • Fax: 904-827-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101929
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: