Basic Information
Provider Information
NPI: 1003001058
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BELANGER
FirstName: AYUMI
MiddleName: E
NamePrefix: MS.
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1978
Address2:  
City: MIDDLEBURG
State: FL
PostalCode: 320501978
CountryCode: US
TelephoneNumber: 9042826331
FaxNumber: 9042821550
Practice Location
Address1: 91 BRANSCOMB RD
Address2: SUITE 3
City: GREEN COVE SPRINGS
State: FL
PostalCode: 320437223
CountryCode: US
TelephoneNumber: 9048611034
FaxNumber: 9048611037
Other Information
ProviderEnumerationDate: 09/12/2007
LastUpdateDate: 06/19/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AM0700XPA 9104224FLY Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical

ID Information
IDTypeStateIssuerDescription
29284260005FL MEDICAID


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