Provider Demographics
NPI:1558633602
Name:BOYD, JENNIFER MICHELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BOYD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 16TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-4719
Mailing Address - Country:US
Mailing Address - Phone:727-512-2319
Mailing Address - Fax:
Practice Address - Street 1:636 16TH AVE NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4719
Practice Address - Country:US
Practice Address - Phone:727-512-2319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9106425363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical