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General NPI Number Information
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NPI Number | 1821466491
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Entity Type | Organization
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Legal Business Name | NORTHWEST FLORIDA ENT PA
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Dates
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Enumeration Date | 09/12/2015
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Last Update Date | 04/13/2019
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Provider Practice Location Address
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Address Line | 310 RACETRACK RD NW STE 100
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1553
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Country | US
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Telephone | 850-889-4550
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Fax | 850-889-4549
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Provider Business Mailing Address
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Address Line | 310 RACETRACK RD NW
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1553
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Country | US
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Telephone | 850-889-4550
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Fax | 850-807-5217
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Authorized Official
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Title or Position | PRESIDENT
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Name | JASON REDWOOD BOOLE
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Credential |
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Telephone | 850-889-4550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0602X
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Taxonomy Name | Otolaryngic Allergy Physician
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License Number | ME96773
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207YS0012X
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Taxonomy Name | Sleep Medicine (Otolaryngology) Physician
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License Number | ME96773
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | ME96773
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License Number State | FL
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