Provider Demographics
NPI:1063618338
Name:EISENBERG, ERIC SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:SCOTT
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12670 CREEKSIDE LN 202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3370
Mailing Address - Country:US
Mailing Address - Phone:239-482-2663
Mailing Address - Fax:239-482-7585
Practice Address - Street 1:12670 CREEKSIDE LN 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3370
Practice Address - Country:US
Practice Address - Phone:239-482-2663
Practice Address - Fax:239-482-7585
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108735363A00000X
MI5601005654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIH297ZMedicare PIN