Provider Demographics
NPI:1831165638
Name:BULLARD, GARY PHILLIP (PA-C)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:PHILLIP
Last Name:BULLARD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4566 E HIGHWAY 20 STE 105
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8839
Mailing Address - Country:US
Mailing Address - Phone:850-279-4543
Mailing Address - Fax:850-279-4827
Practice Address - Street 1:4566 E HIGHWAY 20 STE 105
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8839
Practice Address - Country:US
Practice Address - Phone:850-279-4543
Practice Address - Fax:850-279-4827
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00280363AM0700X
FLPA9104382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty