Provider Demographics
NPI:1568437119
Name:CHAMBERLAIN, BRIAN KEITH (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743409
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3409
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-532-1325
Practice Address - Street 1:455 PINELLAS ST
Practice Address - Street 2:#320
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3354
Practice Address - Country:US
Practice Address - Phone:727-446-2273
Practice Address - Fax:727-441-4966
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291808100Medicaid
FL225992OtherWELLCARE
R97710Medicare UPIN
FL291808100Medicaid
FL225992OtherWELLCARE