Healthcare Provider Details

I. General information

NPI: 1174069710
Provider Name (Legal Business Name): KATHERINE DEUTCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2789 ORTIZ AVE
FORT MYERS FL
33905-7806
US

IV. Provider business mailing address

3763 EVANS AVE
FORT MYERS FL
33901-9302
US

V. Phone/Fax

Practice location:
  • Phone: 239-275-3222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9110110
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: