Provider Demographics
NPI:1073928537
Name:HAGERTY, JASON R (NP-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:HAGERTY
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:727-568-6011
Practice Address - Street 1:1120 10TH ST E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-4134
Practice Address - Country:US
Practice Address - Phone:941-847-7903
Practice Address - Fax:941-847-7919
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16064-NP261QU0200X, 363LF0000X
FLARNP9396930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014664800Medicaid