Basic Information
| Provider Information | |||||||||
| NPI: | 1548588262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25487 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342772487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412025342 | ||||||||
| FaxNumber: | 8552534836 | ||||||||
| Practice Location | |||||||||
| Address1: | 6110 S.R. 70 EAST (53RD AVE) | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417554242 | ||||||||
| FaxNumber: | 9417551906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 9105384 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | Y0F6V | 01 | FL | BCBS | OTHER | 008214900 | 05 | FL | MEDICAID | PA9105384 | 01 | FL | FL PHYSICIAN ASSISTANT LICENSE NUMBER | OTHER |