Healthcare Provider Details

I. General information

NPI: 1740796770
Provider Name (Legal Business Name): LEE WILLIAM ELGIN III MSN, CRNP, AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARRICOLA AVE
ST AUGUSTINE FL
32080-4515
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 1
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4568
  • Fax:
Mailing address:
  • Phone: 904-293-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-108603
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11002556
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: