Basic Information
| Provider Information | |||||||||
| NPI: | 1174517403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROVANCE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY | ||||||||
| Address2: | STE 301 | ||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992625 | ||||||||
| Practice Location | |||||||||
| Address1: | 681 GOODLETTE RD N | ||||||||
| Address2: | STE 130 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396439767 | ||||||||
| FaxNumber: | 2396495878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/24/2006 | ||||||||
| NPIReactivationDate: | 08/03/2007 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | OS12406 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P00252222 | 01 | PA | PALMETTOGBA | OTHER | 0013977160006 | 05 | PA | MEDICAID |