Healthcare Provider Details

I. General information

NPI: 1295350411
Provider Name (Legal Business Name): TIAN LUO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 PINE RIDGE RD
NAPLES FL
34119-3900
US

IV. Provider business mailing address

5401 MAHOGANY RIDGE DR
NAPLES FL
34119-2535
US

V. Phone/Fax

Practice location:
  • Phone: 239-348-4000
  • Fax:
Mailing address:
  • Phone: 239-273-0396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113383
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPA9113383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: