Provider Demographics
NPI:1609438316
Name:FAGERBERG, BRADLEE
Entity Type:Individual
Prefix:
First Name:BRADLEE
Middle Name:
Last Name:FAGERBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14598 WAKE ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-1415
Mailing Address - Country:US
Mailing Address - Phone:352-817-5776
Mailing Address - Fax:
Practice Address - Street 1:9330 FL-54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655
Practice Address - Country:US
Practice Address - Phone:727-834-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant