Provider Demographics
NPI:1164192100
Name:NOGGLE, SHAUN DARREN (PA)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:DARREN
Last Name:NOGGLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17951 TROPICAL COVE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3672
Mailing Address - Country:US
Mailing Address - Phone:910-583-0902
Mailing Address - Fax:
Practice Address - Street 1:1201 ORIENT RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-3325
Practice Address - Country:US
Practice Address - Phone:813-247-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant