Provider Demographics
NPI:1497190524
Name:MCDANIEL, LAYLA BROCK (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAYLA
Middle Name:BROCK
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1660 PRUDENTIAL DR
Practice Address - Street 2:SUITE 310
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8197
Practice Address - Country:US
Practice Address - Phone:904-396-8656
Practice Address - Fax:904-396-5931
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102092363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHG416ZMedicare PIN