Basic Information
Provider Information | |||||||||
NPI: | 1114245370 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MERRITT | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | JOSEPHINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEAVER | ||||||||
OtherFirstName: | SARA | ||||||||
OtherMiddleName: | JOSEPHINE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3152 LITTLE RD # 162 | ||||||||
Address2: |   | ||||||||
City: | TRINITY | ||||||||
State: | FL | ||||||||
PostalCode: | 346551864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273459615 | ||||||||
FaxNumber: | 7273459635 | ||||||||
Practice Location | |||||||||
Address1: | 301 MEMORIAL MEDICAL PKWY | ||||||||
Address2: |   | ||||||||
City: | DAYTONA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321175167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3862316000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2010 | ||||||||
LastUpdateDate: | 03/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9112233 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | MA053442 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 104059300 | 05 | FL |   | MEDICAID |