Provider Demographics
NPI:1982168118
Name:SOUTH, JOE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:
Last Name:SOUTH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N FEDERAL HWY APT 408
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-3483
Mailing Address - Country:US
Mailing Address - Phone:352-431-0989
Mailing Address - Fax:
Practice Address - Street 1:2502 W SAINT ISABEL ST STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6318
Practice Address - Country:US
Practice Address - Phone:813-874-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant