Healthcare Provider Details

I. General information

NPI: 1013428549
Provider Name (Legal Business Name): ANDREA SOLEDAD PAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 CLYDE MORRIS BLVD STE 100
PORT ORANGE FL
32129-2349
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-1242
  • Fax: 386-756-8802
Mailing address:
  • Phone: 904-398-7205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME168842
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: