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General NPI Number Information
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NPI Number | 1295745560
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Entity Type | Organization
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Legal Business Name | GULF COAST PODIATRY, PA
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Dates
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Enumeration Date | 08/09/2006
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Last Update Date | 11/18/2020
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Provider Practice Location Address
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Address Line | 2507 HARRISON AVE UNIT 201
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City | PANAMA CITY
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State | FL
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Zip | 32405-4447
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Country | US
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Telephone | 850-769-0325
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Fax | 850-769-4476
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Provider Business Mailing Address
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Address Line | 2507 HARRISON AVE UNIT 201
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City | PANAMA CITY
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State | FL
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Zip | 32405-4447
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Country | US
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Telephone | 850-769-0325
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Fax | 850-769-4476
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHAYNE JENSEN
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Credential | DMD
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Telephone | 850-769-0325
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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