Individual
MR. BRENT S MICKLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
14534 OLD SAINT AUGUSTINE RD STE 3420, JACKSONVILLE, FL 32258-2616
(904) 493-8001
(904) 338-0852
Mailing address
PO BOX 43667, JACKSONVILLE, FL 32203-3667
(904) 720-0599
(904) 376-4036
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0010-05496
NC
363A00000X
Physician Assistant
Primary
PA9103362
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
018231000
—
FL
01
—
P01718560
RR MEDICARE
FL
Enumeration date
07/31/2006
Last updated
03/31/2020
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