Healthcare Provider Details

I. General information

NPI: 1336964105
Provider Name (Legal Business Name): JOSHUA PAUL FLADGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 APACHE AVE
SANTA FE NM
87505-3212
US

IV. Provider business mailing address

20548 VENTURA BLVD APT 407
WOODLAND HILLS CA
91364-6472
US

V. Phone/Fax

Practice location:
  • Phone: 480-255-4766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1770
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: