Provider Demographics
NPI:1225280464
Name:GILL, SUSAN M (PAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:GILL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:2350 VANDERBILT BEACH RD STE 201
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2760
Practice Address - Country:US
Practice Address - Phone:239-592-5864
Practice Address - Fax:239-592-6214
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000470400Medicaid
FLAU295XMedicare PIN
FLAU295YMedicare PIN
AU295VMedicare PIN
FL000470400Medicaid
FLAU295WMedicare PIN