Basic Information
| Provider Information | |||||||||
| NPI: | 1003878026 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PERRY | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7855 ARGYLE FOREST BLVD. | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322445597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9042824117 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 KINGSLEY AVE | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042647517 | ||||||||
| FaxNumber: | 9042640015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9103649 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 293082000 | 05 | FL | MEDICAID |