Healthcare Provider Details

I. General information

NPI: 1447461421
Provider Name (Legal Business Name): ST. AUGUSTINE PEDIATRIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 PROSPERITY LAKE DR
ST AUGUSTINE FL
32092-5045
US

IV. Provider business mailing address

493 PROSPERITY LAKE DR
ST AUGUSTINE FL
32092-5045
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-5437
  • Fax: 904-824-7575
Mailing address:
  • Phone: 904-824-5437
  • Fax: 904-824-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME78696
License Number StateFL

VIII. Authorized Official

Name: MICHAEL SOBERANO
Title or Position: OWNER
Credential: M.D.
Phone: 904-824-5437