Provider Demographics
NPI:1578873535
Name:HARTLEY, DARYL KEITH (PA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:KEITH
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-6650
Mailing Address - Fax:321-434-5864
Practice Address - Street 1:699 W COCOA BEACH CSWY STE 503
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3562
Practice Address - Country:US
Practice Address - Phone:321-434-6650
Practice Address - Fax:321-434-5864
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116370363A00000X, 363AM0700X
NY014243-1363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ7657OtherMEDICARE HF
FL118743900Medicaid