Provider Demographics
NPI:1073506614
Name:PASTIZZO, GARY F (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:F
Last Name:PASTIZZO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 403444
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3444
Mailing Address - Country:US
Mailing Address - Phone:813-348-6915
Mailing Address - Fax:
Practice Address - Street 1:4516 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2732
Practice Address - Country:US
Practice Address - Phone:813-348-6915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110033363A00000X
CT000626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
00420017701OtherANTHEM BLUE CROSS
CTP3501542OtherOXFORD
CT010626OtherCONNECTICARE
290000626CT02OtherANTHEM BLUE CROSS
CT2V6674OtherHEALTH NET
CT003006269Medicaid
CTP3501542OtherOXFORD
CTPENDING - C00814Medicare PIN
CT970001789Medicare PIN