Basic Information
| Provider Information | |||||||||
| NPI: | 1639506199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREWER | ||||||||
| FirstName: | KACIE | ||||||||
| MiddleName: | JUNE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD | ||||||||
| Address2: | STE 4015 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506017 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 PRUDENTIAL DR STE 1100 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043886518 | ||||||||
| FaxNumber: | 9043841005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9107527 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0110005142 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 009664700 | 05 | FL | MEDICAID | 003140599A | 05 | GA | MEDICAID | 003140599B | 05 | GA | MEDICAID |