Provider Demographics
NPI:1033867544
Name:FAGAN, JOSHUA J (FNP)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:J
Last Name:FAGAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 63RD AVE S APT 515
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-6311
Mailing Address - Country:US
Mailing Address - Phone:727-656-1341
Mailing Address - Fax:
Practice Address - Street 1:2240 63RD AVE S APT 515
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-6311
Practice Address - Country:US
Practice Address - Phone:727-656-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily