Provider Demographics
NPI:1851493134
Name:JANKE, BRIAN JANKE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JANKE
Last Name:JANKE
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 362
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32923-0362
Mailing Address - Country:US
Mailing Address - Phone:321-615-4800
Mailing Address - Fax:321-574-0590
Practice Address - Street 1:205 PLATT AVE
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4963
Practice Address - Country:US
Practice Address - Phone:321-615-4800
Practice Address - Fax:321-574-0590
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102122363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9613OtherMEDICARE GROUP ID #
FLK9613OtherMEDICARE GROUP ID #
FLE8387BMedicare ID - Type Unspecified