Healthcare Provider Details

I. General information

NPI: 1477029353
Provider Name (Legal Business Name): JUSTIN FLEEGLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 CHRISTIANA ROAD SUITE 202
NEWARK DE
19713
US

IV. Provider business mailing address

774 CHRISTIANA ROAD SUITE 202
NEWARK DE
19713
US

V. Phone/Fax

Practice location:
  • Phone: 302-366-7671
  • Fax: 302-366-7549
Mailing address:
  • Phone: 302-366-7671
  • Fax: 302-366-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC5-0001271
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: