1013176031 NPI number — PABLO MANUEL DEJESUS PHYSICIAN ASSISTANT

Table of content: PABLO MANUEL DEJESUS PHYSICIAN ASSISTANT (NPI 1013176031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013176031 NPI number — PABLO MANUEL DEJESUS PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEJESUS
Provider First Name:
PABLO
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

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:
1013176031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 PINE CONE DR STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32137-8683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-445-6191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PALM COAST FAMILY PRACTICE
Provider Second Line Business Practice Location Address:
9 PINE CONE DRIVE, SUITE 102
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-445-6191
Provider Business Practice Location Address Fax Number:
386-445-3916
Provider Enumeration Date:
06/05/2008

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: 363AM0700X , with the licence number:  PA9114008 , 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)





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