Provider Demographics
NPI:1760784656
Name:THOMAS, SHIRLETTE DEBRA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SHIRLETTE
Middle Name:DEBRA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
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:239-424-1449
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:13340 METRO PKWY STE 310
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4818
Practice Address - Country:US
Practice Address - Phone:239-343-1105
Practice Address - Fax:239-343-1106
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014451363A00000X
FLPA 9105819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010245000Medicaid