Healthcare Provider Details

I. General information

NPI: 1124704119
Provider Name (Legal Business Name): NICHOLAS JOSEPH CONBOY CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 W UNDERWOOD ST
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

3890 FOX LAKE RD
TITUSVILLE FL
32796-4037
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5111
  • Fax:
Mailing address:
  • Phone: 321-615-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA864
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: