Provider Demographics
NPI:1508659111
Name:BAGLEY, JULIAN ALEXANDER
Entity type:Individual
Prefix:
First Name:JULIAN
Middle Name:ALEXANDER
Last Name:BAGLEY
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 1:7901 4TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 LAKE POINTE DR APT 202
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-3536
Practice Address - Country:US
Practice Address - Phone:954-632-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW459944390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program