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General NPI Number Information
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NPI Number | 1013176031
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Entity Type | Individual
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Provider Name | PABLO MANUEL DEJESUS PHYSICIAN ASSISTANT
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Gender | Male
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Dates
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Enumeration Date | 06/05/2008
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Last Update Date | 12/19/2023
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Provider Practice Location Address
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Address Line | PALM COAST FAMILY PRACTICE 9 PINE CONE DRIVE, SUITE 102
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City | PALM COAST
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State | FL
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Zip | 32137
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Country | US
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Telephone | 386-445-6191
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Fax | 386-445-3916
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Provider Business Mailing Address
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Address Line | 9 PINE CONE DR STE 102
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City | PALM COAST
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State | FL
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Zip | 32137-8683
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Country | US
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Telephone | 386-445-6191
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9114008
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License Number State | FL
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