Provider Demographics
NPI:1023360294
Name:AGE, DAMARIS (PA-C)
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:AGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:963 TOWN CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8254
Mailing Address - Country:US
Mailing Address - Phone:386-774-9880
Mailing Address - Fax:386-774-2898
Practice Address - Street 1:963 TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8254
Practice Address - Country:US
Practice Address - Phone:217-238-3000
Practice Address - Fax:217-238-3008
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085004462363A00000X
FLPA9110129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant