Healthcare Provider Details

I. General information

NPI: 1538418934
Provider Name (Legal Business Name): JASON DANIEL FAGAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 WEBB DR STE 300
DAVENPORT FL
33837-3951
US

IV. Provider business mailing address

141 WEBB DR STE 300
DAVENPORT FL
33837-3951
US

V. Phone/Fax

Practice location:
  • Phone: 863-422-0020
  • Fax: 863-422-0021
Mailing address:
  • Phone: 863-422-0020
  • Fax: 863-422-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113844
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: