Provider Demographics
NPI:1447513718
Name:AGAN, TINA MAREE (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MAREE
Last Name:AGAN
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 TELECOM DRIVE, SUITE 300W
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7501 142ND AVE
Practice Address - Street 2:LOT 530
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-4610
Practice Address - Country:US
Practice Address - Phone:727-754-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9369198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009642500Medicaid