Provider Demographics
NPI:1194787804
Name:PATZWAHL, BRUCE A (PA-C)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:PATZWAHL
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 1:632 DEL PRADO BLVD N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2278
Mailing Address - Country:US
Mailing Address - Phone:239-772-5577
Mailing Address - Fax:239-772-9961
Practice Address - Street 1:12700 CREEKSIDE LN
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3356
Practice Address - Country:US
Practice Address - Phone:239-432-0774
Practice Address - Fax:239-432-9404
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA1782363AS0400X, 207T00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2902397-00Medicaid
FLY00LXOtherBCBS
FLY00LXOtherBCBS
FL2902397-00Medicaid