Provider Demographics
NPI:1003878026
Name:PERRY, PETER (PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PERRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7855 ARGYLE FOREST BLVD.
Mailing Address - Street 2:STE. 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5597
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-282-4117
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:SUITE 6A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-264-7517
Practice Address - Fax:904-264-0015
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103649363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL293082000Medicaid
FL293082000Medicaid