=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649354812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMIE LEE DURCHIN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 09/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1409 MEADOWBROOK AVE
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-709-8543
-----------------------------------------------------
Fax | 863-688-2520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 CRYSTAL LAKE DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33801-5979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-709-9392
-----------------------------------------------------
Fax | 863-688-2520
-----------------------------------------------------
=====================================================
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 | PA9109519
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MA052770
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------