Healthcare Provider Details

I. General information

NPI: 1891730008
Provider Name (Legal Business Name): TABARE D TABAR P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4990 GOLDEN GATE PKWY
NAPLES FL
34116-6962
US

IV. Provider business mailing address

4990 GOLDEN GATE PKWY
NAPLES FL
34116-6962
US

V. Phone/Fax

Practice location:
  • Phone: 239-692-8309
  • Fax: 239-692-8504
Mailing address:
  • Phone: 239-692-8309
  • Fax: 239-692-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01537
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105645
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: