Provider Demographics
NPI:1740271717
Name:FERGUSON, DAVID W (PA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:240 N WICKHAM RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8663
Mailing Address - Country:US
Mailing Address - Phone:321-541-1777
Mailing Address - Fax:321-541-1786
Practice Address - Street 1:240 N WICKHAM RD STE 104
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8663
Practice Address - Country:US
Practice Address - Phone:321-541-1777
Practice Address - Fax:321-541-1786
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3501363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2072ZMedicare ID - Type UnspecifiedMEDICARE