Provider Demographics
NPI:1376889022
Name:SPATHAROS, JODI ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ELLEN
Last Name:SPATHAROS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:ELLEN
Other - Last Name:STEELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1478 SUNKIST WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-3117
Mailing Address - Country:US
Mailing Address - Phone:239-641-6042
Mailing Address - Fax:
Practice Address - Street 1:8350 RIVERWALK PARK BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8759
Practice Address - Country:US
Practice Address - Phone:239-482-5399
Practice Address - Fax:239-482-4353
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant