Provider Demographics
NPI:1053329599
Name:GHANDOUR, DEBORAH LANE (PA-C, DHSC)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:LANE
Last Name:GHANDOUR
Suffix:
Gender:F
Credentials:PA-C, DHSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 3RD ST N STE B
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4840
Mailing Address - Country:US
Mailing Address - Phone:904-595-5826
Mailing Address - Fax:904-595-5827
Practice Address - Street 1:1825 3RD ST N STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4840
Practice Address - Country:US
Practice Address - Phone:904-595-5826
Practice Address - Fax:904-595-5827
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP68274Medicare UPIN
FLE8164AMedicare PIN