Provider Demographics
NPI:1407816234
Name:LOCKETT, AMY JOY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JOY
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5011 GATE PARKWAY
Mailing Address - Street 2:BLDG 100 STE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5597
Mailing Address - Country:US
Mailing Address - Phone:904-512-7239
Mailing Address - Fax:904-512-7239
Practice Address - Street 1:5011 GATE PARKWAY
Practice Address - Street 2:BLDG 100 STE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-3225
Practice Address - Country:US
Practice Address - Phone:904-512-7239
Practice Address - Fax:866-380-0827
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9112255207R00000X, 208VP0014X
NC103487363AM0700X, 363AS0400X
FL9112255363AM0700X
FLPA9112255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103867800Medicaid