Coastline Primary Care | |
109 W Knapp Ave Edgewater FL 32132-1555 | |
(386) 957-4100 | |
(386) 957-4104 |
Full Name | Coastline Primary Care |
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Speciality | Family Medicine |
Location | 109 W Knapp Ave, Edgewater, Florida |
Authorized Official Name and Position | Carissa Peterson (OWNER/APRN) |
Authorized Official Contact | 3869574100 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Coastline Primary Care 109 W Knapp Ave Edgewater FL 32132-1555 Ph: (386) 957-4100 | Coastline Primary Care 109 W Knapp Ave Edgewater FL 32132-1555 Ph: (386) 957-4100 |
NPI Number | 1114572245 |
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Provider Enumeration Date | 08/06/2019 |
Last Update Date | 04/26/2022 |
Medicare PECOS PAC ID | 8123356946 |
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Medicare Enrollment ID | O20190819000269 |
Identifier | Type | State | Issuer |
---|---|---|---|
1114572245 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207QA0505X | Family Medicine - Adult Medicine | (* (Not Available)) | Primary |
Provider Name | Carissa J Peterson |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1376097105 PECOS PAC ID: 2466738521 Enrollment ID: I20190819000443 |
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