Basic Information
Provider Information | |||||||||
NPI: | 1174660823 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARTLETT | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | DUANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3434 HANCOCK BRIDGE PKWY | ||||||||
Address2: | STE 301 | ||||||||
City: | N FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339037094 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778563774 | ||||||||
FaxNumber: | 2395992625 | ||||||||
Practice Location | |||||||||
Address1: | 2400 S MCCALL RD | ||||||||
Address2: | STE C | ||||||||
City: | ENGLEWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 342245137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9414749314 | ||||||||
FaxNumber: | 9414739813 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 02/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2579 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.