Basic Information
Provider Information | |||||||||
NPI: | 1336542075 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCARTHY | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | VERONICA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEONARD | ||||||||
OtherFirstName: | SARA | ||||||||
OtherMiddleName: | VERONICA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 705 WELLS RD STE 300 | ||||||||
Address2: |   | ||||||||
City: | ORANGE PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 320732982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042826331 | ||||||||
FaxNumber: | 9046191080 | ||||||||
Practice Location | |||||||||
Address1: | 1865 LIME STREET | ||||||||
Address2: | SUITE 100 | ||||||||
City: | FERNANDINA BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 32034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043218400 | ||||||||
FaxNumber: | 9043218401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2014 | ||||||||
LastUpdateDate: | 01/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9108202 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.