Provider Demographics
NPI:1144848649
Name:DEGIDIO, JON-MICHAEL
Entity type:Individual
Prefix:
First Name:JON-MICHAEL
Middle Name:
Last Name:DEGIDIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 17TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-5719
Mailing Address - Country:US
Mailing Address - Phone:954-770-2837
Mailing Address - Fax:
Practice Address - Street 1:9330 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1808
Practice Address - Country:US
Practice Address - Phone:727-834-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT135-0000069367H00000X
FLAA584367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant