=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346747425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH ANGELA FERDMAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2018
-----------------------------------------------------
Last Update Date | 08/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 GATEWAY CIR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-4082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-544-5800
-----------------------------------------------------
Fax | 904-544-5800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 PASEO REYES DR
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-8464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-544-5800
-----------------------------------------------------
Fax | 904-544-5800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 0219591
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9116854
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------