Provider Demographics
NPI:1417924317
Name:DOUGLAS, JAMIE N (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:N
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JAMIE
Other - Middle Name:L
Other - Last Name:NEITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 COLUMBIA DR
Practice Address - Street 2:STE 730
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3589
Practice Address - Country:US
Practice Address - Phone:813-259-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP84475Medicare UPIN
FLU5432YMedicare PIN