Provider Demographics
NPI:1477029353
Name:FLEEGLE, JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:FLEEGLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 CHRISTIANA ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-366-7671
Mailing Address - Fax:302-366-7549
Practice Address - Street 1:774 CHRISTIANA ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-366-7671
Practice Address - Fax:302-366-7549
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001271363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty