Provider Demographics
NPI:1306827225
Name:SMITH, DONNA JO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:JO
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11945 SAN JOSE BLVD 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 303
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-399-0350
Practice Address - Fax:904-399-5914
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3168363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133338AMedicaid
FL970010579OtherRAILROAD MEDICARE
FL008639600Medicaid
FLE3064ZMedicare ID - Type Unspecified
FL008639600Medicaid
FLS89317Medicare UPIN
FL970010579OtherRAILROAD MEDICARE