Individual
JACQUELINE INDRISEK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
22655 BAYSHORE RD STE 130, PORT CHARLOTTE, FL 33980-2005
(941) 255-3722
(941) 255-3723
Mailing address
PO BOX 2147, FORT MYERS, FL 33902-2147
(941) 255-3722
(941) 255-3723
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA9108209
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
014722900
—
FL
Enumeration date
03/23/2015
Last updated
06/07/2023
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