NPI |
1568116770 |
|
Entity Type Code |
1 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Provider Last Name Legal Name |
CONCANNON |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Provider First Name |
JOSHUA |
The first name of the provider, if the provider
is an individual. |
Provider First Line Business Practice Location Address |
11225 CYPRESS TRAIL DR |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
ORLANDO |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address State Name |
FL |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
328255027 |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
4077975058 |
The country code in the location address of the provider being identified. |
Provider Enumeration Date |
2/7/2022 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
2/7/2022 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Taxonomy Code 1 |
390200000X |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Sole Proprietor |
Y |
|
NPI Certification Date |
2/7/2022 |
|