Provider Demographics
NPI:1972061570
Name:TANIMOTO, SUZANA (PA-C)
Entity Type:Individual
Prefix:
First Name:SUZANA
Middle Name:
Last Name:TANIMOTO
Suffix:
Gender:F
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 1:77 8TH ST S STE B
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-6111
Mailing Address - Country:US
Mailing Address - Phone:239-325-2015
Mailing Address - Fax:
Practice Address - Street 1:77 8TH ST S STE B
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-6111
Practice Address - Country:US
Practice Address - Phone:239-325-2015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111967207R00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9111967OtherFLORIDA MEDICAL LICENSE