Provider Demographics
NPI:1194870212
Name:PATTERSON, PAUL R (PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:PATTERSON
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 1:2468 BELL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1811
Mailing Address - Country:US
Mailing Address - Phone:910-916-9264
Mailing Address - Fax:
Practice Address - Street 1:BLDG 4315 EL SALVADOR WAY
Practice Address - Street 2:
Practice Address - City:EAFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-885-9979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 910843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant