Provider Demographics
NPI:1689603698
Name:PABEN, GARY ROY (MPT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROY
Last Name:PABEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11441 DANCING RIVER DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4127
Mailing Address - Country:US
Mailing Address - Phone:941-493-6979
Mailing Address - Fax:941-484-5487
Practice Address - Street 1:12497 TAMIAMI TRL S
Practice Address - Street 2:SUITE 12
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-1447
Practice Address - Country:US
Practice Address - Phone:941-426-3934
Practice Address - Fax:941-426-6718
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY85581OtherBLUE CROSS BLUE SHIELD
FL65001784Medicare ID - Type UnspecifiedRAILROAD MEDICARE