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General NPI Number Information
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NPI Number | 1528460425
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Entity Type | Individual
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Provider Name | JOSHUA MICHAEL DEARTH PA-C
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Gender | Male
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Dates
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Enumeration Date | 09/23/2014
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Last Update Date | 04/23/2020
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Provider Practice Location Address
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Address Line | 151 PINE LAKE DR UNIT B
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City | PONTE VEDRA
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State | FL
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Zip | 32081-5136
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Country | US
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Telephone | 904-543-3677
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Fax |
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Provider Business Mailing Address
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Address Line | 151 PINE LAKE DRIVE SUITEB
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City | POINTE VEDRA
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State | FL
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Zip | 32081-2584
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Country | US
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Telephone | 904-543-3677
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9110420
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50-004097
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License Number State | OH
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