Provider Demographics
NPI:1770950420
Name:PEDDYCOART, MICHAEL NATHAN (NP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:NATHAN
Last Name:PEDDYCOART
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7406 FULLERTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3552
Mailing Address - Country:US
Mailing Address - Phone:863-529-6259
Mailing Address - Fax:
Practice Address - Street 1:7406 FULLERTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-3552
Practice Address - Country:US
Practice Address - Phone:863-529-6259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9227732363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN9227732OtherFL APRN LICENSE
FLRN9227732OtherFL RN LICENSE