Provider Demographics
NPI:1346037025
Name:DEMARIO, PHILIP BLAKE
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:BLAKE
Last Name:DEMARIO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 TAMIAMI TRL STE 3157 #522
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950
Mailing Address - Country:US
Mailing Address - Phone:561-441-2557
Mailing Address - Fax:
Practice Address - Street 1:4820 GRIFFIN BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2016
Practice Address - Country:US
Practice Address - Phone:239-208-6648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11038490363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner