MEDICARE: MS. MALISA MARIE WETMORE PA-C

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	PA3665	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528029626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MALISA MARIE WETMORE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 746654
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6654
Country	:	US
Telephone Number	:	904-202-2092
Fax Number	:	904-376-4075

Provider Business Practice Location Address
First Line	:	1301 PALM AVE STE 600
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8432
Country	:	US
Telephone Number	:	904-202-7300
Fax Number	:	904-202-2754

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

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	05/19/2025

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