Provider Demographics
NPI:1578543674
Name:SANSON, INA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:INA
Middle Name:MICHELLE
Last Name:SANSON
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 1:3080 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5730
Mailing Address - Country:US
Mailing Address - Phone:904-213-4298
Mailing Address - Fax:
Practice Address - Street 1:1551 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4124
Practice Address - Country:US
Practice Address - Phone:904-354-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101335363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical