Provider Demographics
NPI:1437451929
Name:BREIVOGEL, DANIEL RAY (NP-C)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:RAY
Last Name:BREIVOGEL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 REMINGTON GREEN CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:
Practice Address - Street 1:1328 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:PANACEA
Practice Address - State:FL
Practice Address - Zip Code:32346-2151
Practice Address - Country:US
Practice Address - Phone:850-984-4735
Practice Address - Fax:850-984-4742
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9316690363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEM733ZOtherMEDICARE PTAN
FL003096900Medicaid