Healthcare Provider Details

I. General information

NPI: 1275356586
Provider Name (Legal Business Name): ALEXANDRA MARIE PUCHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 COLONIAL CT
FORT MYERS FL
33913-6636
US

IV. Provider business mailing address

17343 GULF PRESERVE DR
FORT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 239-274-6070
  • Fax:
Mailing address:
  • Phone: 407-451-9950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9119405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: