Healthcare Provider Details

I. General information

NPI: 1609083724
Provider Name (Legal Business Name): BERNARDUS E RAY CFA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BROADMOOR RD
ROTONDA WEST FL
33947-1901
US

IV. Provider business mailing address

PO BOX 3313
BAY ST LOUIS MS
39521-3313
US

V. Phone/Fax

Practice location:
  • Phone: 941-830-0584
  • Fax:
Mailing address:
  • Phone: 228-342-3831
  • Fax: 985-845-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberCN 2545
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000230
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number1131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: