Provider Demographics
NPI:1568426906
Name:JIMENEZ, ANTHONY JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:JIMENEZ
Suffix:
Gender:M
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 1:403 S KINGS AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5962
Mailing Address - Country:US
Mailing Address - Phone:813-872-4492
Mailing Address - Fax:813-490-9635
Practice Address - Street 1:403 S KINGS AVE STE 201
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5962
Practice Address - Country:US
Practice Address - Phone:813-872-4992
Practice Address - Fax:813-864-4030
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3216363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970022306OtherRAILROAD MEDICARE
FL290370901Medicaid
FLE0408YMedicare PIN
S51909Medicare UPIN
FL290370901Medicaid
FLE0408XMedicare PIN