Provider Demographics
NPI:1639915929
Name:TREJO, MARIA ZULEICA LORA (PA)
Entity type:Individual
Prefix:
First Name:MARIA ZULEICA
Middle Name:LORA
Last Name:TREJO
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4539
Mailing Address - Country:US
Mailing Address - Phone:392-938-2000
Mailing Address - Fax:239-278-0404
Practice Address - Street 1:1550 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4539
Practice Address - Country:US
Practice Address - Phone:239-938-2000
Practice Address - Fax:239-278-0404
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9118858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
16276031OtherCAQH
FL124581200Medicaid