Basic Information
| Provider Information | |||||||||
| NPI: | 1699428680 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FAGO | ||||||||
| FirstName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 DEPT 8272 | ||||||||
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| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328858272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8136586222 | ||||||||
| Practice Location | |||||||||
| Address1: | 13837 CIRCA CROSSING DRIVE | ||||||||
| Address2: | |||||||||
| City: | LITHIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8136586222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.