Provider Demographics
NPI:1699737783
Name:ARDILA, BOBBY JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:JOHN
Last Name:ARDILA
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 1:410 CELEBRATION PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5433
Mailing Address - Country:US
Mailing Address - Phone:407-303-4673
Mailing Address - Fax:407-303-4674
Practice Address - Street 1:410 CELEBRATION PL
Practice Address - Street 2:SUITE 200
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5433
Practice Address - Country:US
Practice Address - Phone:407-303-4673
Practice Address - Fax:407-303-4674
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102779363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291863300Medicaid
FLU2896WMedicare PIN
FLU2896YMedicare PIN
Q20243Medicare UPIN
FL291863300Medicaid