Provider Demographics
NPI:1437112638
Name:MORA, PATRICK G (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:G
Last Name:MORA
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MEYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6341
Mailing Address - Fax:239-343-6342
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-6341
Practice Address - Fax:239-343-6342
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100684363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290465900Medicaid
FL192485OtherAMERIGROUP
FL2904659-00Medicaid
FLE1953WMedicare PIN
FL2904659-00Medicaid
FL192485OtherAMERIGROUP
FL290465900Medicaid
FL290465900Medicaid