1619275559 NPI number — SHARON R MCDADE A.N.P. - B.C.

Table of content: SHARON R MCDADE A.N.P. - B.C. (NPI 1619275559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619275559 NPI number — SHARON R MCDADE A.N.P. - B.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDADE
Provider First Name:
SHARON
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.N.P. - B.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:
1619275559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7015 A C SKINNER PKWY STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-363-7453
Provider Business Mailing Address Fax Number:
229-494-9109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14546 OLD SAINT AUGUSTINE RD STE 317
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32258-5472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-260-9445
Provider Business Practice Location Address Fax Number:
904-260-0005
Provider Enumeration Date:
03/02/2011

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: 363LA2200X , with the licence number:  RN127394 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN9439089 , 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)

  • Identifier: SE6I1 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: L2515 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 105178000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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