MEDICARE: JASON D PENDERGRAPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL4711	FL

General Provider Information

NPI Number	:	1063913861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON D PENDERGRAPH

Provider Business Mailing Address
First Line	:	1834 WHEELER RD
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32563-8824
Country	:	US
Telephone Number	:	850-485-4723
Fax Number	:

Provider Business Practice Location Address
First Line	:	2441 BELLEVUE AVE
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5615
Country	:	US
Telephone Number	:	850-485-4723
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2018
Last Update Date	:	02/27/2018

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Directions to “ JASON D PENDERGRAPH ” Practice Location

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