Provider Demographics
NPI:1659548949
Name:CONDREY, NICOLAS CHARLES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:CHARLES
Last Name:CONDREY
Suffix:
Gender:M
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 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-398-3760
Mailing Address - Fax:904-241-5492
Practice Address - Street 1:1361 13TH AVE S STE 270
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3258
Practice Address - Country:US
Practice Address - Phone:904-241-7147
Practice Address - Fax:904-241-5492
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104578363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012730800Medicaid