Provider Demographics
NPI:1386196426
Name:PETRACCO, GINA (PA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:PETRACCO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15051 S TAMIAMI TRL STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5182
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:25987 S TAMIAMI TRL STE 90
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7810
Practice Address - Country:US
Practice Address - Phone:239-444-3201
Practice Address - Fax:239-992-9359
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9109770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical