Provider Demographics
NPI:1659384766
Name:DEGOURSEY, KATHRYN TYRRELL (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:TYRRELL
Last Name:DEGOURSEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:TYRRELL
Other - Last Name:PEABODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10058 BAYMEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7177
Mailing Address - Country:US
Mailing Address - Phone:904-636-5400
Mailing Address - Fax:904-928-0654
Practice Address - Street 1:3550 UNIVERSITY BLVD S STE 302
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-733-4444
Practice Address - Fax:904-733-5377
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009353600Medicaid
FL018008600Medicaid
FLE1468SMedicare PIN