Provider Demographics
NPI:1457309601
Name:MUNIZZA, VINCENT S (PA)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:S
Last Name:MUNIZZA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12550 PROFESSIONAL PARK DR.
Mailing Address - Street 2:SUITE 11
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913
Mailing Address - Country:US
Mailing Address - Phone:239-768-2111
Mailing Address - Fax:239-482-4404
Practice Address - Street 1:13650 METROPOLIS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-768-2111
Practice Address - Fax:239-482-4404
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA2064208000000X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290123400Medicaid