Provider Demographics
NPI:1194766675
Name:CALLAHAN, WILLIAM PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:PATRICK
Last Name:CALLAHAN
Suffix:
Gender:M
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:7335 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5101
Practice Address - Country:US
Practice Address - Phone:239-985-1925
Practice Address - Fax:239-321-6044
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000309363A00000X
FLPA9108409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9605646OtherAETNA
FLY0S4VOtherBCBS
FL1249040OtherWELLCARE
FLP01522201OtherRAILROAD MEDICARE
FLP1031192OtherFREEDOM
FL015294300Medicaid
FL5339736OtherCIGNA
FLP967778OtherOPTIMUM
FL5339736OtherCIGNA
FLP01522201OtherRAILROAD MEDICARE
CT970000893Medicare PIN