MEDICARE: MRS. MINDY M BRYDE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	5601004388	MI
2	363AS0400X	Surgical Physician Assistant	5601004388	MI
3	363A00000X	Physician Assistant	PA9109096	FL

General Provider Information

NPI Number	:	1619994068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MINDY M BRYDE PA

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-424-1449
Fax Number	:	239-424-1421

Provider Business Practice Location Address
First Line	:	2780 CLEVELAND AVE
Second Line	:	SUITE 819
City	:	FORT MYERS
State	:	FL
Zip	:	33901-5858
Country	:	US
Telephone Number	:	239-343-3800
Fax Number	:	239-343-3993

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	11/02/2015

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