Provider Demographics
NPI:1164654778
Name:MCBRIDE, MICHELLE AMELIA (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:AMELIA
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6890 BELFORT OAKS PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6241
Mailing Address - Country:US
Mailing Address - Phone:904-296-1313
Mailing Address - Fax:
Practice Address - Street 1:9905 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8982
Practice Address - Country:US
Practice Address - Phone:904-880-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY06K9OtherBCBS
FLEP682ZMedicare PIN