MEDICARE: MR. MICHAEL NATHAN PEDDYCOART NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	APRN9227732	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APRN9227732	OTHER	FL	FL APRN LICENSE

General Provider Information

NPI Number	:	1770950420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL NATHAN PEDDYCOART NP

Provider Business Mailing Address
First Line	:	7406 FULLERTON ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-3552
Country	:	US
Telephone Number	:	863-529-6259
Fax Number	:

Provider Business Practice Location Address
First Line	:	7406 FULLERTON ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-3552
Country	:	US
Telephone Number	:	863-529-6259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2015
Last Update Date	:	07/02/2020

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