Provider Demographics
NPI:1154028751
Name:DEMILLE, JEREMY KNIGHT (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:KNIGHT
Last Name:DEMILLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14540 OLD ST. AUGUSTINE RD.
Mailing Address - Street 2:#2571
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258
Mailing Address - Country:US
Mailing Address - Phone:904-510-5170
Mailing Address - Fax:
Practice Address - Street 1:14540 OLD ST. AUGUSTINE RD.
Practice Address - Street 2:#2571
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-886-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116800363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical