Provider Demographics
NPI:1508582933
Name:FIDLER, ASHLEY RENEE (PA)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:RENEE
Last Name:FIDLER
Suffix:
Gender:F
Credentials:PA
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:239-343-1176
Mailing Address - Fax:239-343-4238
Practice Address - Street 1:13685 DOCTORS WAY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4337
Practice Address - Country:US
Practice Address - Phone:239-343-1176
Practice Address - Fax:239-343-4238
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116656208600000X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116383700Medicaid