Basic Information
| Provider Information | |||||||||
| NPI: | 1245540632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGERTON | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13020 N TELECOM PKWY | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8135586187 | ||||||||
| Practice Location | |||||||||
| Address1: | 6117 GUNN HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8135586187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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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 | 363AM0700X | PA9105738 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA9105738 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | Y09H3 | 01 | FL | BCBS | OTHER | PA9105738 | 01 | FL | STATE LICENSE | OTHER | 004380300 | 05 | FL | MEDICAID |