=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942332135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN L MINER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 05/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 WELLS ROAD SUITE 17
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-2900
-----------------------------------------------------
Fax | 904-269-1140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 WELLS ROAD SUITE 17
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-2900
-----------------------------------------------------
Fax | 904-269-1140
-----------------------------------------------------
=====================================================
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 | PA2719
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------