Provider Demographics
NPI:1619926169
Name:JAMES, GARY (RPA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:JAMES
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1981
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1350 HICKORY ST STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-1401
Practice Address - Fax:321-434-1667
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110289363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022838200Medicaid
FLJE476ZOtherMEDICARE
FLJE476YOtherMEDICARE