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General NPI Number Information
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NPI Number | 1821196924
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Entity Type | Individual
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Provider Name | LATRESE S ANDRE PAC
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Gender | Female
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 1000 RIVERSIDE AVE STE 200
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4154
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Country | US
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Telephone | 904-388-7521
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Fax | 904-388-3541
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Provider Business Mailing Address
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Address Line | 1824 KING ST STE 200
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4736
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Country | US
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Telephone | 904-384-3343
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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 | PA100931
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License Number State | FL
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