Provider Demographics
NPI:1689889818
Name:JUNGENBERG, GREGORY LYLE (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LYLE
Last Name:JUNGENBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-326-7342
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:1302 RIVER ST
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-5042
Practice Address - Country:US
Practice Address - Phone:386-328-8371
Practice Address - Fax:386-328-1519
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 1724363AM0700X
FLPA1724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018954700Medicaid