Provider Demographics
NPI:1073007076
Name:PILIEGO, JUSTIN SHAWN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SHAWN
Last Name:PILIEGO
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 1:500 KNIGHTS RUN AVE UNIT 1408
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-6015
Mailing Address - Country:US
Mailing Address - Phone:813-410-1109
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-5779
Practice Address - Country:US
Practice Address - Phone:352-273-6438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA479367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101160200Medicaid