Healthcare Provider Details

I. General information

NPI: 1104978287
Provider Name (Legal Business Name): BRENT DAVIN HOPSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 US 1 S
ST AUGUSTINE FL
32086
US

IV. Provider business mailing address

3100 US1 SOUTH MIDFLORIDA DERMATOLOGY AND PLASTIC SURGERY
ST AUGUSTINE FL
32086-0258
US

V. Phone/Fax

Practice location:
  • Phone: 407-299-7333
  • Fax:
Mailing address:
  • Phone: 407-299-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: