=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104777598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY RON ALQUIZAR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2026
-----------------------------------------------------
Last Update Date | 02/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1851 OLD MOULTRIE RD
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-4168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-8088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7154 AMBROSIUS WAY
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32258-6541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-887-7459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | APRN11043624
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------