Provider Demographics
NPI:1215556634
Name:MECKA, DAVID MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:MECKA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 STAR LEAF RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-9605
Mailing Address - Country:US
Mailing Address - Phone:757-515-9063
Mailing Address - Fax:
Practice Address - Street 1:100 WHETSTONE PL STE 102
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5775
Practice Address - Country:US
Practice Address - Phone:904-342-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9113289363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty