Provider Demographics
NPI:1154512358
Name:PEREZ, GARY CHARLES (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CHARLES
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 REDSTONE AVE W
Mailing Address - Street 2:SUITE 370
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6428
Mailing Address - Country:US
Mailing Address - Phone:850-682-2209
Mailing Address - Fax:850-850-6822
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:SUITE 370
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-682-2209
Practice Address - Fax:850-850-6822
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002879600Medicaid
PA9103949OtherPA LICENSE
FL1467589010Medicaid
592921954OtherTAX ID MEDICARE GROUP
FL1467589010OtherMEDICARE NPI GROUP
PA9103949OtherPA LICENSE