Provider Demographics
NPI:1215955760
Name:PINELLO, ROBERT RICHARD (PAC MPAS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RICHARD
Last Name:PINELLO
Suffix:
Gender:M
Credentials:PAC MPAS
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1400
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:SUITE 2310
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8130
Practice Address - Country:US
Practice Address - Phone:239-992-0558
Practice Address - Fax:239-992-2663
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004478OtherGA MEDICAL BOARD PA LICEN
GA9338Medicaid
GA97WCGLCMedicare ID - Type Unspecified