Provider Demographics
NPI:1639841299
Name:GEORGIEV, ANTON S (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANTON
Middle Name:S
Last Name:GEORGIEV
Suffix:
Gender:M
Credentials:PMHNP-BC
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 54723
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-4723
Mailing Address - Country:US
Mailing Address - Phone:904-239-3677
Mailing Address - Fax:
Practice Address - Street 1:6950 PHILIPS HWY STE 11
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6082
Practice Address - Country:US
Practice Address - Phone:904-239-3677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015748363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114459600Medicaid
FL9377096OtherREGISTERED NURSE