Provider Demographics
NPI:1407864275
Name:GANTZ, ANNA LISA (ARNP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:LISA
Last Name:GANTZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 64TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-4825
Mailing Address - Country:US
Mailing Address - Phone:317-709-5122
Mailing Address - Fax:
Practice Address - Street 1:6300 46TH AVE N
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-3104
Practice Address - Country:US
Practice Address - Phone:727-544-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000770A363LF0000X
FLARNP9337370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S99013Medicare UPIN
274250WWMedicare ID - Type Unspecified