1174265268 NPI number — MR. NINO ANTHONY FAJARDO AGACNP-BC

Table of content: MR. NINO ANTHONY FAJARDO AGACNP-BC (NPI 1174265268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174265268 NPI number — MR. NINO ANTHONY FAJARDO AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAJARDO
Provider First Name:
NINO ANTHONY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174265268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-821-8038
Provider Business Mailing Address Fax Number:
813-974-0483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24323 PAINTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAND O LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34639-5459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-409-8812
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  11014439 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2B2SJ . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 114149900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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