Healthcare Provider Details

I. General information

NPI: 1598206633
Provider Name (Legal Business Name): STINA ROSANNA MCKENNA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8381 RIVERWALK PARK BLVD STE 201
FORT MYERS FL
33919-8760
US

IV. Provider business mailing address

8381 RIVERWALK PARK BLVD STE 201
FORT MYERS FL
33919-8760
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-5425
  • Fax:
Mailing address:
  • Phone: 239-936-5425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9110251
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: