Healthcare Provider Details

I. General information

NPI: 1558879767
Provider Name (Legal Business Name): DEMI SOULET PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13691 METROPOLIS AVE
FORT MYERS FL
33912-4318
US

IV. Provider business mailing address

1512 WHISKEY CREEK DR
FORT MYERS FL
33919-2702
US

V. Phone/Fax

Practice location:
  • Phone: 888-540-9660
  • Fax: 239-561-3020
Mailing address:
  • Phone: 407-247-7421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: