Healthcare Provider Details

I. General information

NPI: 1316488455
Provider Name (Legal Business Name): CARRIE JEAN BAUER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 HARBOR BLVD
PORT CHARLOTTE FL
33952-6720
US

IV. Provider business mailing address

6321 DANIELS PKWY STE 200
FORT MYERS FL
33912-4710
US

V. Phone/Fax

Practice location:
  • Phone: 941-883-2199
  • Fax: 941-979-5041
Mailing address:
  • Phone: 239-396-5162
  • Fax: 239-645-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110023
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: