Provider Demographics
NPI:1811236110
Name:KUSMIEREK, CHRISTIE A (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:A
Last Name:KUSMIEREK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTIE
Other - Middle Name:
Other - Last Name:FREESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
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:239-343-2052
Mailing Address - Fax:239-343-5348
Practice Address - Street 1:9981 S HEALTHPARK DR # 2-WEST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-2052
Practice Address - Fax:239-343-5348
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015921100Medicaid