=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851493134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN JANKE JANKE PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 12/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 PLATT AVE
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-4963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-615-4800
-----------------------------------------------------
Fax | 321-574-0590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 362
-----------------------------------------------------
City | COCOA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32923-0362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-615-4800
-----------------------------------------------------
Fax | 321-574-0590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA 9102122
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------