Individual
MIRIAN ANTELO COUCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6555 CHESTER AVE STE 1, JACKSONVILLE, FL 32217-2279
(904) 309-6504
(904) 503-3577
Mailing address
6555 CHESTER AVE STE 1, JACKSONVILLE, FL 32217-2279
(904) 265-8209
(904) 503-3577
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA9106827
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100513100
—
FL
01
—
Y0FR9
BCBS
—
Enumeration date
11/15/2012
Last updated
02/28/2022
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