Healthcare Provider Details

I. General information

NPI: 1851472187
Provider Name (Legal Business Name): MICHAEL A BANUCHI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 JACARANDA BLVD.
VENICE FL
34292-4522
US

IV. Provider business mailing address

15051 S. TAMIAMI TRAIL SUITE 203
FORT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 941-484-1510
  • Fax: 941-484-1071
Mailing address:
  • Phone: 239-437-8810
  • Fax: 239-313-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: