Basic Information
| Provider Information | |||||||||
| NPI: | 1952838898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NACKE | ||||||||
| FirstName: | BEAU | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19038 LAKE SWATARA DR | ||||||||
| Address2: | |||||||||
| City: | EUSTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327367709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524097943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048195155 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2017 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9110469 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.