Provider Demographics
NPI:1275518086
Name:CRUZ, GERARDO (PA-C)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DR
Mailing Address - Street 2:INTERNAL MEDICINE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8202
Mailing Address - Fax:850-862-6148
Practice Address - Street 1:1005 MAR WALT DR
Practice Address - Street 2:INTERNAL MEDICINE DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-8202
Practice Address - Fax:850-862-6148
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290987100Medicaid
P27389Medicare UPIN
FL290987100Medicaid