Provider Demographics
NPI:1023293420
Name:BERNARDINO, VIRGILIO (PA)
Entity type:Individual
Prefix:
First Name:VIRGILIO
Middle Name:
Last Name:BERNARDINO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5233 RICKER ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1439
Mailing Address - Country:US
Mailing Address - Phone:904-425-6963
Mailing Address - Fax:904-674-0155
Practice Address - Street 1:5233 RICKER ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1439
Practice Address - Country:US
Practice Address - Phone:904-425-6963
Practice Address - Fax:904-674-0155
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100905363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1951AOtherBPC GRP PTAN
FLK1951AOtherBPC GRP PTAN