Provider Demographics
NPI:1174265268
Name:FAJARDO, NINO ANTHONY (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:NINO ANTHONY
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-821-8038
Mailing Address - Fax:813-974-0483
Practice Address - Street 1:24323 PAINTER DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5459
Practice Address - Country:US
Practice Address - Phone:863-409-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-10
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014439363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2B2SJOtherBCBS
FL114149900Medicaid