Provider Demographics
NPI:1801609151
Name:DUSTIN, BRIANNA BLAKE (PA-C)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:BLAKE
Last Name:DUSTIN
Suffix:
Gender:
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 1:100 NW 170TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5511
Mailing Address - Country:US
Mailing Address - Phone:305-651-3033
Mailing Address - Fax:
Practice Address - Street 1:100 NW 170TH ST STE 301
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5511
Practice Address - Country:US
Practice Address - Phone:305-651-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program