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: 07/27/2026
Certification Date: 07/27/2026
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

PO BOX 100225
GAINESVILLE FL
32610-0225
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8666
  • Fax: 904-824-8933
Mailing address:
  • Phone: 352-273-8737
  • Fax: 352-265-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9237428
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9237428
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: