Healthcare Provider Details

I. General information

NPI: 1962985416
Provider Name (Legal Business Name): PATRICK EDWARD TOLAN III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9368 NARCOOSSEE RD STE 104
ORLANDO FL
32827-5704
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 866-400-3376
  • Fax: 407-650-3455
Mailing address:
  • Phone: 866-400-3376
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111562
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: