Provider Demographics
NPI:1073358552
Name:GOLDICH, BRIAN (APRN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GOLDICH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 MADEIRA CIR
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-1986
Mailing Address - Country:US
Mailing Address - Phone:727-793-5893
Mailing Address - Fax:
Practice Address - Street 1:4111 LAND O LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-4437
Practice Address - Country:US
Practice Address - Phone:813-929-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033680363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily