Provider Demographics
NPI:1124034269
Name:MICKLEY, BRENT S (PA)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:S
Last Name:MICKLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-720-0599
Mailing Address - Fax:904-376-4036
Practice Address - Street 1:14534 OLD SAINT AUGUSTINE RD STE 3420
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2616
Practice Address - Country:US
Practice Address - Phone:904-493-8001
Practice Address - Fax:904-338-0852
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05496363A00000X
FLPA9103362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018231000Medicaid
FLP01718560OtherRR MEDICARE
FLU5786WMedicare PIN
FLQ51209Medicare UPIN
FLU5786XMedicare PIN
FL292199500Medicaid