Provider Demographics
NPI:1083383699
Name:PERLY, BROCK (PA-C)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:PERLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:661 E ALTAMONTE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5103
Mailing Address - Country:US
Mailing Address - Phone:407-303-4120
Mailing Address - Fax:407-303-4124
Practice Address - Street 1:661 E ALTAMONTE DR STE 325
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5103
Practice Address - Country:US
Practice Address - Phone:407-303-4120
Practice Address - Fax:407-303-4124
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9114893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant