Provider Demographics
NPI:1609868835
Name:BANDERAS, PABLO RODRIGO (PA)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:RODRIGO
Last Name:BANDERAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:126 DEL PRADO BLVD N
Practice Address - Street 2:STE 104
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2713
Practice Address - Country:US
Practice Address - Phone:239-573-1606
Practice Address - Fax:239-573-1044
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFB349ZMedicare PIN