MEDICARE: PENNIC, WOOTEN& ASSOCIATES FAMILY MEDICAL CARE 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	207Q00000X	Family Medicine Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34367	OTHER	FL	BLUECROSS BLUESHIELD #

General Provider Information

NPI Number	:	1194789958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENNIC, WOOTEN& ASSOCIATES FAMILY MEDICAL CARE PA

Provider Business Mailing Address
First Line	:	1760 EDGEWOOD AVE W
Second Line	:	B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-7209
Country	:	US
Telephone Number	:	904-358-8480
Fax Number	:	904-358-8460

Provider Business Practice Location Address
First Line	:	1760 EDGEWOOD AVE W
Second Line	:	B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-7209
Country	:	US
Telephone Number	:	904-358-8480
Fax Number	:	904-358-8460

Authorized Official
Title or Position	:	OFFICE MANANGER
Name	:	SONYA LUCAS
Credential	:
Telephone Number	:	904-358-8480

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/21/2022

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