Provider Demographics
NPI:1205879137
Name:BELANGER, GARY L (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:BELANGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17567
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:SUITE 231
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-469-7975
Practice Address - Fax:850-469-2113
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA279363A00000X
FLPA9106277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-50070OtherBCBS OF ALABAMA
AL528701110Medicaid
ALCA0084OtherRR MEDICARE
AL051512155OtherBLUE CROSS BLUE SHIELD AL
AL528701110Medicaid
AL051512155OtherBLUE CROSS BLUE SHIELD AL
ALCA0084OtherRR MEDICARE