Provider Demographics
NPI:1104978287
Name:HOPSON, BRENT DAVIN (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:DAVIN
Last Name:HOPSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 US1 SOUTH
Mailing Address - Street 2:MIDFLORIDA DERMATOLOGY AND PLASTIC SURGERY
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-0258
Mailing Address - Country:US
Mailing Address - Phone:407-299-7333
Mailing Address - Fax:
Practice Address - Street 1:3100 US 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:407-299-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS85940Medicare UPIN
S85940Medicare UPIN
0PA154660Medicare ID - Type Unspecified