Provider Demographics
NPI:1003969627
Name:PRIMEAUX, MIKE J (APRN-BC)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:J
Last Name:PRIMEAUX
Suffix:
Gender:M
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10601 SAN JOSE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8203
Mailing Address - Country:US
Mailing Address - Phone:904-379-5052
Mailing Address - Fax:
Practice Address - Street 1:10601 SAN JOSE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8203
Practice Address - Country:US
Practice Address - Phone:904-379-5052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12392363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3349995Medicare PIN
TN3349995Medicare PIN