Provider Demographics
NPI:1487643110
Name:GARTNER, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GARTNER
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 1:1403 TIBURON CT
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-1800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 NW 7TH AVE
Practice Address - Street 2:PHOENIX EMERGENCY MEDICINE OF BROWARD, LLC
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-9026
Practice Address - Country:US
Practice Address - Phone:954-759-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292108100Medicaid
FLE6648OtherMEDICARE CORE
FLE6448YMedicare PIN
FL292108100Medicaid
FLE6648XMedicare PIN