Provider Demographics
NPI:1699259333
Name:KOTTLER, JORDAN ABRAHAM (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ABRAHAM
Last Name:KOTTLER
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 1:1005 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-243-0118
Mailing Address - Fax:850-243-0594
Practice Address - Street 1:1000 MAR WALT DRIVE
Practice Address - Street 2:WWMC INTENSIVITS PROGRAM
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-243-0118
Practice Address - Fax:850-243-0594
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant