Provider Demographics
NPI:1700138625
Name:WALGATE, LAURA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:A
Last Name:WALGATE
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 1:15051 S TAMIAMI TRL STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5182
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:413 DEL PRADO BLVD S STE 101
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5703
Practice Address - Country:US
Practice Address - Phone:239-443-1500
Practice Address - Fax:239-443-1510
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP944517OtherOPTIMUM
FL9275941OtherAETNA
FLY04EHOtherBCBS FL
FLP01118217OtherRAILROAD MCR
FLP1004406OtherFREEDOM HEALTH
FLP1004406OtherFREEDOM HEALTH