Provider Demographics
NPI:1780126839
Name:PULAYYA, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PULAYYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4958 KEY LIME DR UNIT 105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3253
Mailing Address - Country:US
Mailing Address - Phone:321-946-8441
Mailing Address - Fax:
Practice Address - Street 1:3 SHIRCLIFF WAY STE 400
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4780
Practice Address - Country:US
Practice Address - Phone:904-381-9393
Practice Address - Fax:904-381-9314
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109984363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019564200Medicaid