1194787804 NPI number — BRUCE A. PATZWAHL PA-C

Table of content: BRUCE A. PATZWAHL PA-C (NPI 1194787804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194787804 NPI number — BRUCE A. PATZWAHL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATZWAHL
Provider First Name:
BRUCE
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194787804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
632 DEL PRADO BLVD N
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33909-2278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-772-5577
Provider Business Mailing Address Fax Number:
239-772-9961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12700 CREEKSIDE LN
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33919-3356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-432-0774
Provider Business Practice Location Address Fax Number:
239-432-9404
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  PA1782 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207T00000X , with the licence number: PA1782 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA1782 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2902397-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y00LX . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 290239700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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