MEDICARE: MR. DAVID W FERGUSON P.A.

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	363AM0700X	Medical Physician Assistant	PA3501	FL

General Provider Information

NPI Number	:	1740271717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID W FERGUSON P.A.

Provider Business Mailing Address
First Line	:	240 N WICKHAM RD STE 104
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8663
Country	:	US
Telephone Number	:	321-541-1777
Fax Number	:	321-541-1786

Provider Business Practice Location Address
First Line	:	240 N WICKHAM RD STE 104
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8663
Country	:	US
Telephone Number	:	321-541-1777
Fax Number	:	321-541-1786

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	10/03/2022

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