Basic Information
Provider Information | |||||||||
NPI: | 1710388871 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | PHILIP | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12470 TELECOM DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | TEMPLE TERRACE | ||||||||
State: | FL | ||||||||
PostalCode: | 336370904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8137796303 | ||||||||
FaxNumber: | 8889771998 | ||||||||
Practice Location | |||||||||
Address1: | 12470 TELECOM DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | TEMPLE TERRACE | ||||||||
State: | FL | ||||||||
PostalCode: | 336370904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8137796303 | ||||||||
FaxNumber: | 8889771998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2014 | ||||||||
LastUpdateDate: | 11/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 110747 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 110747 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 9390792 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 110747 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2100X | APRN9390792 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 013934100 | 05 | FL |   | MEDICAID |