MEDICARE: SUZANA TANIMOTO PA-C

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	207R00000X	Internal Medicine Physician	PA9111967	FL
2	207W00000X	Ophthalmology Physician	PA9111967	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA9111967	OTHER	FL	FLORIDA MEDICAL LICENSE

General Provider Information

NPI Number	:	1972061570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANA TANIMOTO PA-C

Provider Business Mailing Address
First Line	:	77 8TH ST S STE B
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34102-6111
Country	:	US
Telephone Number	:	239-325-2015
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 8TH ST S STE B
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34102-6111
Country	:	US
Telephone Number	:	239-325-2015
Fax Number	:

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

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	03/04/2019

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Directions to “ SUZANA TANIMOTO PA-C” Practice Location

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