MEDICARE: MS. KRISTIN J OVADAL PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	608023	WI
2	363A00000X	Physician Assistant	PA9113677	FL
3	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063407930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTIN J OVADAL PAC

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-541-7500
Fax Number	:	239-541-7501

Provider Business Practice Location Address
First Line	:	4771 S CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1317
Country	:	US
Telephone Number	:	239-343-9800
Fax Number	:	239-343-9848

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	12/03/2025

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