Provider Demographics
NPI:1609178805
Name:TETLOW, MEGAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:L
Last Name:TETLOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:L
Other - Last Name:PADUCHOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:8931 COLONIAL CENTER DR
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-334-6626
Practice Address - Fax:239-334-0404
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9106624OtherAETNA
FLP00900586OtherRAILROAD MCR
FL003024700Medicaid
FL003024700Medicaid