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General NPI Number Information
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NPI Number | 1962465492
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Entity Type | Individual
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Provider Name | ELYSE M FETCKO P.A.
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Gender | Female
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Dates
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Enumeration Date | 04/07/2006
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Last Update Date | 06/22/2018
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Provider Practice Location Address
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Address Line | 6101 PINE RIDGE RD
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City | NAPLES
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State | FL
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Zip | 34119
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Country | US
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Telephone | 239-348-4221
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Fax | 239-348-4529
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Provider Business Mailing Address
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Address Line | PO BOX 11392
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City | BELFAST
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State | ME
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Zip | 04915-4004
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Country | US
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Telephone | 866-949-1433
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9101083
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License Number State | FL
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