Provider Demographics
NPI:1083681357
Name:HERRON, LAUREL ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:ELIZABETH
Last Name:HERRON
Suffix:
Gender:F
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:11761 BEACH BLVD
Practice Address - Street 2:UFJAX - ST. JOHNS BLUFF PRIMARY CARE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6615
Practice Address - Country:US
Practice Address - Phone:904-633-0585
Practice Address - Fax:904-633-0586
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2911078-00Medicaid
FLP41375Medicare UPIN
FL970021909Medicare PIN
FLE6288ZMedicare PIN