Healthcare Provider Details

I. General information

NPI: 1952679136
Provider Name (Legal Business Name): MICHAEL J FARLESS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4427 EMERSON ST. #4
JACKSONVILLE FL
32207-4969
US

IV. Provider business mailing address

75 REMIT DR #1056
CHICAGO IL
60675-1056
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-7015
  • Fax:
Mailing address:
  • Phone: 866-916-5259
  • Fax: 231-922-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8912
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003442
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107975
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: