Provider Demographics
NPI:1780129965
Name:BEERBOWER, NOLAN (PA)
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:BEERBOWER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 PORTER RD STE 205
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8915
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:
Practice Address - Street 1:17000 PORTER RD STE 205
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8915
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:321-842-0460
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110095363A00000X
FLPA9110095363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019925700Medicaid