Provider Demographics
NPI:1073506614
Name:PASTIZZO, GARY F (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:F
Last Name:PASTIZZO
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 1:18951 ROSEATE DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-2316
Mailing Address - Country:US
Mailing Address - Phone:860-604-2998
Mailing Address - Fax:
Practice Address - Street 1:9332 STATE ROAD 54 STE 405
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1810
Practice Address - Country:US
Practice Address - Phone:727-375-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110033363A00000X, 363AS0400X
CT000626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010626OtherCONNECTICARE
CT2V6674OtherHEALTH NET
00420017701OtherANTHEM BLUE CROSS
290000626CT02OtherANTHEM BLUE CROSS
CTP3501542OtherOXFORD
CT003006269Medicaid
CTP3501542OtherOXFORD
CTPENDING - C00814Medicare PIN
CT970001789Medicare PIN