Provider Demographics
NPI:1093573693
Name:FAJARDO, AUGUSTO (APRN)
Entity Type:Individual
Prefix:
First Name:AUGUSTO
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6487 NEW INDEPENDENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-6217
Mailing Address - Country:US
Mailing Address - Phone:786-879-1655
Mailing Address - Fax:
Practice Address - Street 1:6487 NEW INDEPENDENCE PKWY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-6217
Practice Address - Country:US
Practice Address - Phone:786-879-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily