Healthcare Provider Details

I. General information

NPI: 1962465492
Provider Name (Legal Business Name): ELYSE M FETCKO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 PINE RIDGE RD
NAPLES FL
34119
US

IV. Provider business mailing address

PO BOX 11392
BELFAST ME
04915-4004
US

V. Phone/Fax

Practice location:
  • Phone: 239-348-4221
  • Fax: 239-348-4529
Mailing address:
  • Phone: 866-949-1433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101083
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: