Provider Demographics
NPI:1407592272
Name:CARMEN MICHELLE LITZLER PA
Entity Type:Organization
Organization Name:CARMEN MICHELLE LITZLER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MINUTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-488-0706
Mailing Address - Street 1:13731 METROPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-7150
Mailing Address - Country:US
Mailing Address - Phone:239-565-0978
Mailing Address - Fax:
Practice Address - Street 1:13731 METROPOLIS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7150
Practice Address - Country:US
Practice Address - Phone:239-565-0978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004727200Medicaid