Provider Demographics
NPI:1164532552
Name:BEARD, ALICE G (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:G
Last Name:BEARD
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 1:10476 SPOTTED FAWN LANE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257
Mailing Address - Country:US
Mailing Address - Phone:561-707-8225
Mailing Address - Fax:
Practice Address - Street 1:105 SOUTHPARK BLVD
Practice Address - Street 2:A103
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5191
Practice Address - Country:US
Practice Address - Phone:904-342-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC37626036Medicare PIN