Provider Demographics
NPI:1538678248
Name:BLACK, IAN CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:CHARLES
Last Name:BLACK
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 MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-2606
Mailing Address - Fax:239-343-3695
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901
Practice Address - Country:US
Practice Address - Phone:239-343-2606
Practice Address - Fax:239-343-3695
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110602363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022370000Medicaid