Provider Demographics
NPI:1245299767
Name:FLETCHER, PATRICIA ANN (PA)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E JAMES LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-3118
Mailing Address - Country:US
Mailing Address - Phone:850-689-7808
Mailing Address - Fax:850-689-5928
Practice Address - Street 1:810 E JAMES LEE BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3118
Practice Address - Country:US
Practice Address - Phone:850-689-7808
Practice Address - Fax:850-689-5928
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291595200Medicaid
FLP92272Medicare UPIN
FLU0889YMedicare ID - Type Unspecified