Provider Demographics
NPI:1487804035
Name:BUCK, TANYA L (PA)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:BUCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15051 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5182
Mailing Address - Country:US
Mailing Address - Phone:239-437-8810
Mailing Address - Fax:239-313-2555
Practice Address - Street 1:1108 GOODLETTE RD N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5451
Practice Address - Country:US
Practice Address - Phone:239-434-0303
Practice Address - Fax:239-262-8730
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9104764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000181500Medicaid
FLY0H9NOtherBCBS OF FL
FLY0H9NOtherBCBS OF FL
FL000181500Medicaid