Provider Demographics
NPI:1871682955
Name:CROGNALE, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CROGNALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15215 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6072
Mailing Address - Country:US
Mailing Address - Phone:352-799-0046
Mailing Address - Fax:352-597-1446
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-597-9095
Practice Address - Fax:352-597-1446
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA1694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291499900Medicaid
FLY01EKOtherBCBS
FLU6603AMedicare PIN
FLCD8188OtherRR MEDICARE
FLQ58780Medicare UPIN