Provider Demographics
NPI:1285610899
Name:TARTARILLA, PAUL (APRN)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:TARTARILLA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DR
Mailing Address - Street 2:PEDIATRIC DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8203
Mailing Address - Fax:850-862-0977
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:PEDIATRIC DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-8203
Practice Address - Fax:850-863-8113
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN2897842363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY9978OtherBCBSFL
FL301514900Medicaid
S54518Medicare UPIN
FL301514900Medicaid
FL301514900Medicaid