Basic Information
| Provider Information | |||||||||
| NPI: | 1871682955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROGNALE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15215 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527990046 | ||||||||
| FaxNumber: | 3525971446 | ||||||||
| Practice Location | |||||||||
| Address1: | 11373 CORTEZ BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525979095 | ||||||||
| FaxNumber: | 3525971446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1694 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 291499900 | 05 | FL | MEDICAID | Y01EK | 01 | FL | BCBS | OTHER |