Provider Demographics
NPI:1700427333
Name:ABBOTT, TONY LEE
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:LEE
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 73RD CT
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-7110
Mailing Address - Country:US
Mailing Address - Phone:386-365-6242
Mailing Address - Fax:
Practice Address - Street 1:1050 NW 8TH AVE STE 20
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4998
Practice Address - Country:US
Practice Address - Phone:352-379-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily