Healthcare Provider Details

I. General information

NPI: 1124034269
Provider Name (Legal Business Name): BRENT S MICKLEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14534 OLD SAINT AUGUSTINE RD STE 3420
JACKSONVILLE FL
32258-2616
US

IV. Provider business mailing address

PO BOX 43667
JACKSONVILLE FL
32203-3667
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-8001
  • Fax: 904-338-0852
Mailing address:
  • Phone: 904-720-0599
  • Fax: 904-376-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05496
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103362
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: