Provider Demographics
NPI:1063435600
Name:KEANE, ELIZABETH J (PAC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:KEANE
Suffix:
Gender:F
Credentials:PAC
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Mailing Address - Street 1:1325 SAN MARCO BLVD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8568
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6490
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 2201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7418
Practice Address - Country:US
Practice Address - Phone:904-880-1260
Practice Address - Fax:904-880-1210
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-03-26
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Provider Licenses
StateLicense IDTaxonomies
FLAL20502255A2300X
FLPA9106645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer