Provider Demographics
NPI:1982100939
Name:BRUGGEMAN, CAROL (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BRUGGEMAN
Suffix:
Gender:F
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 1:1230 PENMAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3670
Mailing Address - Country:US
Mailing Address - Phone:941-993-7754
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610
Practice Address - Country:US
Practice Address - Phone:352-265-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1982100939Medicaid
FLPA9111178OtherFLORIDA DEPARTMENT OF HEALTH