Provider Demographics
NPI:1376885996
Name:WASHINGTON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7152 COCA SABAL LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4263
Mailing Address - Country:US
Mailing Address - Phone:239-939-9939
Mailing Address - Fax:239-931-5020
Practice Address - Street 1:7152 COCA SABAL LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4263
Practice Address - Country:US
Practice Address - Phone:239-939-9939
Practice Address - Fax:239-931-5060
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1376885996OtherNPI
FL009809200Medicaid
FLHC769YOtherMEDICARE