Provider Demographics
NPI:1902843352
Name:KMETZ, JOHN PETER (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PETER
Last Name:KMETZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 WINKLER AVE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9523
Mailing Address - Country:US
Mailing Address - Phone:239-277-7070
Mailing Address - Fax:239-277-7071
Practice Address - Street 1:3033 WINKLER AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9523
Practice Address - Country:US
Practice Address - Phone:239-277-7070
Practice Address - Fax:239-277-7071
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1731363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3464527OtherCIGNA
FL36291OtherBCBS
FL065642900Medicaid
FL9423471OtherAETNA
FLPA0001731OtherPA LICENSE
FL1902843352OtherTRICARE
FL36291OtherBCBS
FL9423471OtherAETNA
FLE1193YMedicare PIN
FL1902843352OtherTRICARE
FLS63019Medicare UPIN