Healthcare Provider Details

I. General information

NPI: 1871533240
Provider Name (Legal Business Name): ALISSA JAN SHAVALIER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALISSA JAN LAGRASTA PAC

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 GOODLETTE RD N STE 204
NAPLES FL
34102-5499
US

IV. Provider business mailing address

1112 GOODLETTE RD N STE 204
NAPLES FL
34102-5499
US

V. Phone/Fax

Practice location:
  • Phone: 239-262-4519
  • Fax: 239-262-5672
Mailing address:
  • Phone: 239-262-4519
  • Fax: 239-262-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: