Healthcare Provider Details

I. General information

NPI: 1609326537
Provider Name (Legal Business Name): EDDY SHANE THOMAS ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD STE 4000
ST AUGUSTINE FL
32086-3704
US

IV. Provider business mailing address

1154 EARLYLIGHT CT
JACKSONVILLE FL
32218
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8666
  • Fax: 904-824-8933
Mailing address:
  • Phone: 904-305-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP9247428
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: