Healthcare Provider Details

I. General information

NPI: 1699259333
Provider Name (Legal Business Name): JORDAN ABRAHAM KOTTLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAR WALT DRIVE WWMC INTENSIVITS PROGRAM
FORT WALTON BEACH FL
32547-6707
US

IV. Provider business mailing address

1005 MAR WALT DR
FORT WALTON BEACH FL
32547-6707
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-0118
  • Fax: 850-243-0594
Mailing address:
  • Phone: 850-243-0118
  • Fax: 850-243-0594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111482
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: