Healthcare Provider Details

I. General information

NPI: 1699663971
Provider Name (Legal Business Name): MATTHEW KELLER MACLARTY PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 HEALTH CENTER BLVD STE 1050
ESTERO FL
34135-8130
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-0260
  • Fax: 239-343-4254
Mailing address:
  • Phone: 239-468-0260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9120407
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9120407
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: