Healthcare Provider Details

I. General information

NPI: 1205909546
Provider Name (Legal Business Name): OLGA POROTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8925 COLONIAL CENTER DR STE 1000
FORT MYERS FL
33905-7813
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9325
  • Fax:
Mailing address:
  • Phone: 239-343-9325
  • Fax: 239-468-7950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112979
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5573
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: