Healthcare Provider Details

I. General information

NPI: 1437112638
Provider Name (Legal Business Name): PATRICK G MORA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9981 S HEALTHPARK DR SUITE 120
FORT MYERS FL
33908-3618
US

IV. Provider business mailing address

PO BOX 2147
FORT MEYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-6341
  • Fax: 239-343-6342
Mailing address:
  • Phone: 239-343-6341
  • Fax: 239-343-6342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9100684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: