Provider Demographics
NPI:1487629267
Name:EWALT, FRED CARTER (PA)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:CARTER
Last Name:EWALT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:904-542-7765
Mailing Address - Fax:904-542-7835
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-542-7765
Practice Address - Fax:904-542-7835
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL1462446363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical