Basic Information
Provider Information | |||||||||
NPI: | 1275141558 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA GULF COAST UNIVERISTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10501 FGCU BLVD S | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339656502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2397424299 | ||||||||
FaxNumber: | 2395907398 | ||||||||
Practice Location | |||||||||
Address1: | 10501 FGCU BLVD S | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339656502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2397424299 | ||||||||
FaxNumber: | 2395907398 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2020 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEAL | ||||||||
AuthorizedOfficialFirstName: | PAULA | ||||||||
AuthorizedOfficialMiddleName: | NECOLE | ||||||||
AuthorizedOfficialTitleorPosition: | ASST. AD FOR HEALTH PERFORMANCE | ||||||||
AuthorizedOfficialTelephone: | 2397454299 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LAT | ||||||||
NPICertificationDate: | 09/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | ME80216 | 01 | FL | STATE LICENSE | OTHER |