Provider Demographics
NPI:1265900336
Name:ESTRADA BAEZA, FERNANDO
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:ESTRADA BAEZA
Suffix:
Gender:M
Credentials:
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:239-343-3800
Mailing Address - Fax:239-343-3893
Practice Address - Street 1:13685 DOCTORS WAY STE 350
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4347
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101459200Medicaid