Provider Demographics
NPI:1366882433
Name:WILEY, BRANDY MANCHE (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:MANCHE
Last Name:WILEY
Suffix:
Gender:F
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 1:4881 NW 8TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4582
Mailing Address - Country:US
Mailing Address - Phone:352-547-2373
Mailing Address - Fax:352-416-1813
Practice Address - Street 1:4343 W NEWBERRY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2817
Practice Address - Country:US
Practice Address - Phone:352-374-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP9107304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009327800Medicaid
FLY0P28OtherBC/BS
FL009327800Medicaid