Provider Demographics
NPI:1215276852
Name:SLATER, GARY WALLACE III (CSFA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:WALLACE
Last Name:SLATER
Suffix:III
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1142
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34697-1142
Mailing Address - Country:US
Mailing Address - Phone:727-204-7315
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1142
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34697-1142
Practice Address - Country:US
Practice Address - Phone:727-204-7315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL129713246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant