Provider Demographics
NPI:1003599564
Name:GREGG, JOSHUA BAILEY
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BAILEY
Last Name:GREGG
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 1:5638 ROCHAMBEAU DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-6036
Mailing Address - Country:US
Mailing Address - Phone:205-382-1129
Mailing Address - Fax:
Practice Address - Street 1:2160 CAPITAL CIR NE STE 200
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4391
Practice Address - Country:US
Practice Address - Phone:850-558-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9119560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program