Provider Demographics
NPI:1336703461
Name:KIETZMAN, AYESHA FALAK (PA)
Entity Type:Individual
Prefix:
First Name:AYESHA
Middle Name:FALAK
Last Name:KIETZMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AYESHA
Other - Middle Name:FALAK
Other - Last Name:HUSSAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14690 SPRING HILL DR STE 305
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:13944 LAKESHORE BLVD STE C
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1431
Practice Address - Country:US
Practice Address - Phone:727-605-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9112195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program