Provider Demographics
NPI:1326353665
Name:SELVAGGIO, JACQUELYN ANNE (AA (ANESTHESIOLOGY)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANNE
Last Name:SELVAGGIO
Suffix:
Gender:F
Credentials:AA (ANESTHESIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10134 DEERCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2936
Mailing Address - Country:US
Mailing Address - Phone:414-336-6646
Mailing Address - Fax:
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:414-336-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
FLAA67367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant