Provider Demographics
NPI:1558360206
Name:REISS, JARED P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:P
Last Name:REISS
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 1:1501 MCGREGOR RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9658
Mailing Address - Country:US
Mailing Address - Phone:407-376-4976
Mailing Address - Fax:321-421-0393
Practice Address - Street 1:4961 ROYAL GULF CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-7006
Practice Address - Country:US
Practice Address - Phone:239-687-4015
Practice Address - Fax:321-421-0393
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3719363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021420100Medicaid
FLE1115ZMedicare ID - Type Unspecified