Provider Demographics
NPI:1760620314
Name:EWBANK, JEREMY PAUL (PA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:PAUL
Last Name:EWBANK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:773 STIRLING CENTER PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4856
Mailing Address - Country:US
Mailing Address - Phone:407-977-4130
Mailing Address - Fax:407-977-4139
Practice Address - Street 1:773 STIRLING CENTER PL
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4856
Practice Address - Country:US
Practice Address - Phone:407-977-4130
Practice Address - Fax:407-977-4139
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant