MEDICARE: MS. MARY JOYCE OHALLORAN 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	PA9108848	FL

General Provider Information

NPI Number	:	1457455743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY JOYCE OHALLORAN PA

Provider Business Mailing Address
First Line	:	14810 OLD SAINT AUGUSTINE RD STE 207
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2558
Country	:	US
Telephone Number	:	904-738-8321
Fax Number	:	904-217-7483

Provider Business Practice Location Address
First Line	:	14810 OLD SAINT AUGUSTINE RD STE 207
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2558
Country	:	US
Telephone Number	:	904-738-8321
Fax Number	:	904-217-7483

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

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	08/31/2023

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Practice Location Address:

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1134167687 — JEAN HELEN MCCLINTOCK MD
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1053336933 — DR. BERNARD H. GUIOT M.D.
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1740361336 — JERRY ALAN BRIDGHAM MD
Practice Location Address:

14810 OLD SAINT AUGUSTINE RD STE 106 , CREDENTIALING DEPARTMENT
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1629159223 — VIRGINIA GIBSON BLACK M.D.
Practice Location Address:

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1306972161 — MRS. ROBIN PAYLOR JOHNSON APRN
Practice Location Address:

14810 OLD SAINT AUGUSTINE RD STE 106
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