Basic Information
| Provider Information | |||||||||
| NPI: | 1962465492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETCKO | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11392 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669491433 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6101 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393484221 | ||||||||
| FaxNumber: | 2393484529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9101083 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 290948100 | 05 | FL | MEDICAID |