Healthcare Provider Details

I. General information

NPI: 1073506614
Provider Name (Legal Business Name): GARY F PASTIZZO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9332 STATE ROAD 54 STE 405
TRINITY FL
34655-1810
US

IV. Provider business mailing address

18951 ROSEATE DR
LUTZ FL
33558-2316
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-8264
  • Fax:
Mailing address:
  • Phone: 860-604-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110033
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9110033
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: