Provider Demographics
NPI:1881938991
Name:COUCH, MIRIAN ANTELO (PA-C)
Entity type:Individual
Prefix:
First Name:MIRIAN
Middle Name:ANTELO
Last Name:COUCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIRIAN
Other - Middle Name:ALICIAN
Other - Last Name:ANTELO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6555 CHESTER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2279
Mailing Address - Country:US
Mailing Address - Phone:904-265-8209
Mailing Address - Fax:904-503-3577
Practice Address - Street 1:6555 CHESTER AVE STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2279
Practice Address - Country:US
Practice Address - Phone:904-309-6504
Practice Address - Fax:904-503-3577
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106827363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100513100Medicaid
Y0FR9OtherBCBS
FL008586300Medicaid