Provider Demographics
NPI:1194789958
Name:PENNIC, WOOTEN& ASSOCIATES FAMILY MEDICAL CARE PA
Entity type:Organization
Organization Name:PENNIC, WOOTEN& ASSOCIATES FAMILY MEDICAL CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-358-8480
Mailing Address - Street 1:1760 EDGEWOOD AVE W
Mailing Address - Street 2:B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-7209
Mailing Address - Country:US
Mailing Address - Phone:904-358-8480
Mailing Address - Fax:904-358-8460
Practice Address - Street 1:1760 EDGEWOOD AVE W
Practice Address - Street 2:B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-7209
Practice Address - Country:US
Practice Address - Phone:904-358-8480
Practice Address - Fax:904-358-8460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34367OtherBLUECROSS BLUESHIELD #