Healthcare Provider Details

I. General information

NPI: 1023076098
Provider Name (Legal Business Name): JIMMIE STONE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851042 US HIGHWAY 17
YULEE FL
32097-2845
US

IV. Provider business mailing address

PO BOX 44008 UFJP - PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0670
  • Fax:
Mailing address:
  • Phone: 904-244-3199
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110000930
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9104733
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: