Provider Demographics
NPI:1508271123
Name:MISEL, AUDREY O'KEEFE (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:O'KEEFE
Last Name:MISEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:O'KEEFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10475 CENTURION PKWY N STE 302
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5004
Mailing Address - Country:US
Mailing Address - Phone:904-398-5437
Mailing Address - Fax:
Practice Address - Street 1:10475 CENTURION PKWY N STE 302
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5004
Practice Address - Country:US
Practice Address - Phone:904-398-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056991363AM0700X
PA9110875363A00000X
FLPA9110875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103156877Medicaid