Provider Demographics
NPI:1326260423
Name:OBRIEN, DENNIS KEVIN (PA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:KEVIN
Last Name:OBRIEN
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 1:1689 EAGLE HARBOR PKWY
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4802
Mailing Address - Country:US
Mailing Address - Phone:904-269-1366
Mailing Address - Fax:904-264-9750
Practice Address - Street 1:1689 EAGLE HARBOR PKWY
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4802
Practice Address - Country:US
Practice Address - Phone:904-269-1366
Practice Address - Fax:904-264-9750
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2391363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5003AMedicare ID - Type Unspecified