Basic Information
| Provider Information | |||||||||
| NPI: | 1154668762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5191 FIRST COAST TECH PKWY | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322240609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | 9042232169 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 PLANTATION ISLAND DR S STE 220 | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320805174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | 9042232169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2013 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107059 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 12999200 | 05 | FL | MEDICAID |