Provider Demographics
NPI:1083093389
Name:FORTH, TORI ELLEN AUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:TORI
Middle Name:ELLEN AUSTIN
Last Name:FORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N JOHN YOUNG PKWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-6601
Mailing Address - Country:US
Mailing Address - Phone:407-624-3062
Mailing Address - Fax:407-613-2223
Practice Address - Street 1:200 N JOHN YOUNG PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-6601
Practice Address - Country:US
Practice Address - Phone:407-624-3062
Practice Address - Fax:407-613-2223
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108460363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical