MEDICARE: MS. BERNICE D BAWAYAN 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	363A00000X	Physician Assistant	011686	NY
2	363A00000X	Physician Assistant	PA9109387	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811103971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BERNICE D BAWAYAN PA

Provider Business Mailing Address
First Line	:	2160 COLONIAL BLVD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1410
Country	:	US
Telephone Number	:	239-931-7342
Fax Number	:	239-931-7385

Provider Business Practice Location Address
First Line	:	8931 COLONIAL CENTER DR STE 100
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-7809
Country	:	US
Telephone Number	:	239-226-2727
Fax Number	:	239-939-9876

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

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	12/01/2025

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