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General NPI Number Information
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NPI Number | 1053329599
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Entity Type | Individual
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Provider Name | DEBORAH LANE GHANDOUR PA-C, DHSC
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Gender | Female
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 12/16/2022
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Provider Practice Location Address
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Address Line | 1825 3RD ST N STE B
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-4840
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Country | US
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Telephone | 904-595-5826
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Fax | 904-595-5827
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Provider Business Mailing Address
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Address Line | 1825 3RD ST N STE B
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-4840
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Country | US
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Telephone | 904-595-5826
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Fax | 904-595-5827
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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 | PA9101774
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License Number State | FL
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