Provider Demographics
NPI:1700134640
Name:KLEIN, BRIAN CHAD (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHAD
Last Name:KLEIN
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:PO BOX 160295
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-0295
Mailing Address - Country:US
Mailing Address - Phone:904-458-1301
Mailing Address - Fax:904-541-0316
Practice Address - Street 1:906 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4120
Practice Address - Country:US
Practice Address - Phone:904-541-0315
Practice Address - Fax:904-541-0316
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08113363A00000X
FLPA9113064363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLYDXC4OtherBCBS