=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639270085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK JOHN REGAN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2402 FRIST BLVD STE 204
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34950-4838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-462-3939
-----------------------------------------------------
Fax | 772-462-3938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2402 FRIST BLVD STE 204
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34950-4838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-462-3939
-----------------------------------------------------
Fax | 772-462-3938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | OS 7803
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------