1982631503 NPI number — LINA LEE FEASTER M.D.

Table of content: LINA LEE FEASTER M.D. (NPI 1982631503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982631503 NPI number — LINA LEE FEASTER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEASTER
Provider First Name:
LINA
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982631503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3463
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32085-3463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-794-2424
Provider Business Mailing Address Fax Number:
904-794-2772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 MARINER HEALTH WAY
Provider Second Line Business Practice Location Address:
STE 207
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-3251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-794-2424
Provider Business Practice Location Address Fax Number:
904-794-2772
Provider Enumeration Date:
06/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME79232 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)