Provider Demographics
NPI:1437600285
Name:HARLACHER, JUSTIN WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WILLIAM
Last Name:HARLACHER
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:239-343-8260
Mailing Address - Fax:239-343-8261
Practice Address - Street 1:5216 CLAYTON CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2116
Practice Address - Country:US
Practice Address - Phone:239-343-8260
Practice Address - Fax:239-424-2442
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9110049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019437800Medicaid