Basic Information
| Provider Information | |||||||||
| NPI: | 1164429346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FICHERA | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2005 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2647 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970016626 | 01 | RR MEDICARE | OTHER | 970016627 | 01 | RR MEDICARE | OTHER | 291070500 | 05 | FL | MEDICAID | 01103936 | 01 | AMERIGROUP | OTHER | 970016628 | 01 | RR MEDICARE | OTHER |