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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746652
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6652
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:1320 ROBERTS DR STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3253
Practice Address - Country:US
Practice Address - Phone:904-241-7147
Practice Address - Fax:904-376-3213
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104578363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012730800Medicaid