Provider Demographics
NPI:1487755054
Name:IVORY, PATRICK JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JOSEPH
Last Name:IVORY
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJAX - DEPT. OF COMMUNITY HEALTH
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-5672
Practice Address - Fax:904-244-5965
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA001735L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0031073-00Medicaid
FLP01206383Medicare PIN
FL0031073-00Medicaid
FLEP121YMedicare PIN
S14041Medicare UPIN