=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407592272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARMEN MICHELLE LITZLER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2022
-----------------------------------------------------
Last Update Date | 05/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13731 METROPOLIS AVE
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-7150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-565-0978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13731 METROPOLIS AVE
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-7150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-565-0978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MINUTHA ASHWIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-488-0706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------