MEDICARE: NORTH LAKE PRIMARY CARE, 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	363LF0000X	Family Nurse Practitioner	363L00000X	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	:	1962809145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH LAKE PRIMARY CARE, P.A.

Provider Business Mailing Address
First Line	:	8022 SAINT JAMES WAY
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-9134
Country	:	US
Telephone Number	:	352-516-8931
Fax Number	:

Provider Business Practice Location Address
First Line	:	8022 SAINT JAMES WAY
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-9134
Country	:	US
Telephone Number	:	352-516-8931
Fax Number	:

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	MR. JEREMY E. CREECH
Credential	:	ARNP
Telephone Number	:	352-516-8931

Provider Enumeration Date	:	12/03/2014
Last Update Date	:	12/03/2014

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