Provider Demographics
NPI:1871597567
Name:PERRY, NOEL MASTERS
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:MASTERS
Last Name:PERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 KING ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4735
Mailing Address - Country:US
Mailing Address - Phone:904-421-5586
Mailing Address - Fax:904-389-6748
Practice Address - Street 1:1824 KING ST
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4735
Practice Address - Country:US
Practice Address - Phone:904-421-5586
Practice Address - Fax:904-389-6748
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1787363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970017538OtherMEDICARE RAILROAD
GA100000513BMedicaid
FL290019000Medicaid
FLE1592YMedicare PIN
FLS67584Medicare UPIN
FLE1592WMedicare PIN
970017538OtherMEDICARE RAILROAD