Provider Demographics
NPI:1003183955
Name:VERGO, THERESA P (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:P
Last Name:VERGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:P
Other - Last Name:FORMICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:681 4TH AVE N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5729
Practice Address - Country:US
Practice Address - Phone:239-434-2622
Practice Address - Fax:239-434-6876
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004381000Medicaid
FLFR195YMedicare PIN
FLFR195ZMedicare PIN
FL004381000Medicaid
FLP938442OtherOPTIMUM
FLP997647OtherFREEDOM HEALTH
FLP01013926OtherRAILROAD MCR
FLY09HLOtherBCBS