Provider Demographics
NPI:1851472187
Name:BANUCHI, MICHAEL A (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BANUCHI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15051 S. TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:1295 JACARANDA BLVD.
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4522
Practice Address - Country:US
Practice Address - Phone:941-484-1510
Practice Address - Fax:941-484-1071
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9102654OtherPA LICENSE