Provider Demographics
NPI:1407885270
Name:BRAZLEY, KIM (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BRAZLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4539
Mailing Address - Country:US
Mailing Address - Phone:239-938-2000
Mailing Address - Fax:239-278-0404
Practice Address - Street 1:1550 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4539
Practice Address - Country:US
Practice Address - Phone:239-938-2000
Practice Address - Fax:239-278-0404
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102785363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2651ZMedicare ID - Type Unspecified
FLS64042Medicare UPIN