MEDICARE: LARA ASHLEY EAST LANEVE 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	PA9103914	FL

General Provider Information

NPI Number	:	1992802912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA ASHLEY EAST LANEVE PA-C

Provider Business Mailing Address
First Line	:	4479 BAYMEADOWS RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4716
Country	:	US
Telephone Number	:	904-731-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4479 BAYMEADOWS RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4716
Country	:	US
Telephone Number	:	904-731-8300
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	11/06/2019

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