Provider Demographics
NPI:1902102445
Name:ROMERO, ALISA K (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:K
Last Name:ROMERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12700 CREEKSIDE LANE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3356
Mailing Address - Country:US
Mailing Address - Phone:239-432-0774
Mailing Address - Fax:239-432-0229
Practice Address - Street 1:12700 CREEKSIDE LANE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3356
Practice Address - Country:US
Practice Address - Phone:239-432-0774
Practice Address - Fax:239-432-9404
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105863363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY06NSOtherBCBS
FL003261200Medicaid
FLEO272ZMedicare PIN
FLY06NSOtherBCBS