Provider Demographics
NPI:1285478644
Name:CEPERO, ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:CEPERO
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: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:239-343-4910
Mailing Address - Fax:239-343-4911
Practice Address - Street 1:3637 DR MARTIN LUTHER KING BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4601
Practice Address - Country:US
Practice Address - Phone:239-343-4910
Practice Address - Fax:239-343-4911
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9118823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123496100Medicaid