=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700427333
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONY LEE ABBOTT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2019
-----------------------------------------------------
Last Update Date | 10/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 NW 8TH AVE STE 20
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32601-4998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-379-7900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11215 73RD CT
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32060-7110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-365-6242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11004396
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------