Provider Demographics
NPI:1689441768
Name:PATACSIL, PHILLIP GRADDY
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:GRADDY
Last Name:PATACSIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9261 CENTRAL PARK DR APT 205
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4838
Mailing Address - Country:US
Mailing Address - Phone:407-446-0136
Mailing Address - Fax:
Practice Address - Street 1:9261 CENTRAL PARK DR APT 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4838
Practice Address - Country:US
Practice Address - Phone:407-446-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program