Provider Demographics
NPI:1235101270
Name:HALL, FREDERICK (PA)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:HALL
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 1:2317 SW 43RD LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-3500
Mailing Address - Country:US
Mailing Address - Phone:239-945-1890
Mailing Address - Fax:
Practice Address - Street 1:2727 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9358
Practice Address - Country:US
Practice Address - Phone:239-939-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE6242YMedicare ID - Type UnspecifiedSOUTHWEST MEDICARE
FLE6242WMedicare PIN
FLP00433681Medicare PIN
FLS12087Medicare UPIN