Provider Demographics
NPI:1255850673
Name:ITZIKOWITZ, JESS (PA-C)
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:
Last Name:ITZIKOWITZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:13340 METRO PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4703
Practice Address - Country:US
Practice Address - Phone:239-343-0550
Practice Address - Fax:239-343-0559
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant