Provider Demographics
NPI:1306314463
Name:KAISER, KAITLYN E (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:E
Last Name:KAISER
Suffix:
Gender:F
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: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:239-468-0145
Mailing Address - Fax:239-343-4054
Practice Address - Street 1:23450 VIA COCONUT PT
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-1877
Practice Address - Country:US
Practice Address - Phone:239-468-0145
Practice Address - Fax:239-343-4054
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101313700Medicaid