Basic Information
| Provider Information | |||||||||
| NPI: | 1225280464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PAC | ||||||||
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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: | 2395992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 VANDERBILT BEACH RD | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341092760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395925684 | ||||||||
| FaxNumber: | 2395926214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9104821 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000470400 | 05 | FL | MEDICAID |