Provider Demographics
NPI:1548588262
Name:DALE, MICHAEL JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:DALE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:855-253-4836
Practice Address - Street 1:6110 S.R. 70 EAST (53RD AVE)
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203
Practice Address - Country:US
Practice Address - Phone:941-755-4242
Practice Address - Fax:941-755-1906
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105384363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0F6VOtherBCBS
FL008214900Medicaid
FLPA9105384OtherFL PHYSICIAN ASSISTANT LICENSE NUMBER
FLDA973WMedicare PIN