Provider Demographics
NPI:1235532730
Name:JAGERNAUTH, ALEXANDER (AA)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:JAGERNAUTH
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 DARLINGTON OAK DR NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-6314
Mailing Address - Country:US
Mailing Address - Phone:727-410-6079
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:STE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8208
Practice Address - Country:US
Practice Address - Phone:904-398-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA225367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant