MEDICARE: JOHN MICHAEL TIERNEY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9102882	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124023445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MICHAEL TIERNEY PA

Provider Business Mailing Address
First Line	:	1325 SAN MARCO BLVD STE 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8566
Country	:	US
Telephone Number	:	904-346-3465
Fax Number	:	904-880-1210

Provider Business Practice Location Address
First Line	:	14540 OLD SAINT AUGUSTINE RD
Second Line	:	SUITE 2201
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-7418
Country	:	US
Telephone Number	:	904-880-1260
Fax Number	:	904-880-1210

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	11/19/2015

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Directions to “ JOHN MICHAEL TIERNEY PA” Practice Location

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