Provider Demographics
NPI:1740796119
Name:PROCKO, PAUL JON
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JON
Last Name:PROCKO
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 1:1945 SAMANTHA LN
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5146
Mailing Address - Country:US
Mailing Address - Phone:407-716-4030
Mailing Address - Fax:
Practice Address - Street 1:7009 DR PHILLIPS BLVD STE 140
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5122
Practice Address - Country:US
Practice Address - Phone:407-412-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5257237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist