Provider Demographics
NPI:1538418934
Name:FAGAN, JASON DANIEL (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DANIEL
Last Name:FAGAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 WEBB DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3951
Mailing Address - Country:US
Mailing Address - Phone:863-422-0020
Mailing Address - Fax:863-422-0021
Practice Address - Street 1:141 WEBB DR STE 300
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3951
Practice Address - Country:US
Practice Address - Phone:863-422-0020
Practice Address - Fax:863-422-0021
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113844363A00000X
NVPA0245363A00000X
NVPA1388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant