Provider Demographics
NPI:1174660823
Name:BARTLETT, GARY DUANE (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DUANE
Last Name:BARTLETT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE 301
Mailing Address - City:N FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:2400 S MCCALL RD
Practice Address - Street 2:STE C
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-5137
Practice Address - Country:US
Practice Address - Phone:941-474-9314
Practice Address - Fax:941-473-9813
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS73205Medicare UPIN
FLE2037YMedicare PIN