Basic Information
| Provider Information | |||||||||
| NPI: | 1578543674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANSON | ||||||||
| FirstName: | INA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3080 COUNTRY CLUB BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320735730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042134298 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1551 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043544488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 03/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9101335 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.