Provider Demographics
NPI:1336818517
Name:HOAGLAND, KARSON NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:KARSON
Middle Name:NICOLE
Last Name:HOAGLAND
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1500
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:4771 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1317
Practice Address - Country:US
Practice Address - Phone:239-343-9800
Practice Address - Fax:239-343-9848
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9114886363A00000X
FLPA9114886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112418700Medicaid