Provider Demographics
NPI:1447942123
Name:FORD, EMERALD DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:EMERALD
Middle Name:DIANE
Last Name:FORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMERALD
Other - Middle Name:DIANE
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10475 CENTURION PKWY N STE 303
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5004
Mailing Address - Country:US
Mailing Address - Phone:229-376-1839
Mailing Address - Fax:
Practice Address - Street 1:10475 CENTURION PKWY N STE 303
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5004
Practice Address - Country:US
Practice Address - Phone:904-399-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117583363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant