=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689117046
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCAS WITMER DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2016
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13670 METROPOLIS AVE SUITE 103
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-4346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-561-0700
-----------------------------------------------------
Fax | 239-561-5643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 HANSON ST
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03820-4113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-605-6116
-----------------------------------------------------
Fax | 603-343-2130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 31740
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------