=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639140411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS FELICIANO PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 11/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 W 8TH ST UFJAX - RADIOLOGY
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32209-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-244-1212
-----------------------------------------------------
Fax | 904-244-1218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 44008 UFJP PROVIDER ENROLLMENT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32231-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-244-3199
-----------------------------------------------------
Fax | 904-244-3425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA3069
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------