Provider Demographics
NPI:1689444184
Name:AGERONE, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:AGERONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-5514
Mailing Address - Country:US
Mailing Address - Phone:786-802-1158
Mailing Address - Fax:
Practice Address - Street 1:5352 LINTON BLVD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6514
Practice Address - Country:US
Practice Address - Phone:561-498-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant