1023112653 NPI number — JEAN L TOLSON PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023112653 NPI number — JEAN L TOLSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOLSON
Provider First Name:
JEAN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1023112653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6550 N FEDERAL HWY
Provider Second Line Business Mailing Address:
SUITE 512
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-1404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-267-8777
Provider Business Mailing Address Fax Number:
954-772-7801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6550 N FEDERAL HWY
Provider Second Line Business Practice Location Address:
SUITE 512
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-267-8777
Provider Business Practice Location Address Fax Number:
954-772-7801
Provider Enumeration Date:
09/12/2006

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: 363AS0400X , with the licence number:  PA 2563 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA0002563 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: E0983V . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00450777 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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