Provider Demographics
NPI:1750706545
Name:AGHAMALIAN, SHEALY (PA-C)
Entity type:Individual
Prefix:
First Name:SHEALY
Middle Name:
Last Name:AGHAMALIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHEALY
Other - Middle Name:
Other - Last Name:WEEKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:841 PRUDENTIAL DR STE 1900
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8373
Mailing Address - Country:US
Mailing Address - Phone:904-633-0926
Mailing Address - Fax:
Practice Address - Street 1:841 PRUDENTIAL DR STE 1900
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8373
Practice Address - Country:US
Practice Address - Phone:904-633-0926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010876900Medicaid
FL010876900Medicaid