Active NPI
Jacqueline Indrisek, PA
- Medical Physician Assistant
- Port Charlotte, FL
National Provider Identifier
1427442011
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- License
- PA9108209
- Practice address
- 22655 Bayshore Rd Ste 130
Port Charlotte, FL 33980-2005 - Phone
- (941) 255-3722
- Fax
- (941) 255-3723
- NPI assigned
- Mar 23, 2015
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | PA9108209 | FL | Primary |
Addresses
Primary practice location
22655 Bayshore Rd Ste 130
Port Charlotte, FL 33980-2005
Mailing address
PO Box 2147
Fort Myers, FL 33902-2147
Phone (941) 255-3722
Other practice location 1
8260 Gladiolus Dr
Fort Myers, FL 33908-4156
Phone (239) 437-5755
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 014722900 | Medicaid | FL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
Interoperability endpoints
- jindrisek283935@direct.leememorial.org
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1427068800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1686096000000",
"number": "1427442011",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 2147",
"city": "FORT MYERS",
"state": "FL",
"postal_code": "339022147",
"telephone_number": "941-255-3722",
"fax_number": "941-255-3723"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "22655 BAYSHORE RD STE 130",
"city": "PORT CHARLOTTE",
"state": "FL",
"postal_code": "339802005",
"telephone_number": "941-255-3722",
"fax_number": "941-255-3723"
}
],
"practiceLocations": [
{
"address_1": "8260 Gladiolus Dr",
"address_purpose": "LOCATION",
"city": "Fort Myers",
"state": "FL",
"postal_code": "339084156",
"country_code": "US",
"telephone_number": "239-437-5755",
"fax_number": "239-437-5776",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "INDRISEK",
"first_name": "JACQUELINE",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2015-03-23",
"last_updated": "2023-06-07",
"certification_date": "2023-06-07",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "FL",
"license": "PA9108209",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "014722900",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Port Charlotte, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.