Provider Demographics
NPI:1346222569
Name:LLISO, FLOR MARITZA (PA)
Entity Type:Individual
Prefix:MRS
First Name:FLOR
Middle Name:MARITZA
Last Name:LLISO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5795 CARRIAGE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-8208
Mailing Address - Country:US
Mailing Address - Phone:912-980-7342
Mailing Address - Fax:
Practice Address - Street 1:5795 CARRIAGE HILLS DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-8208
Practice Address - Country:US
Practice Address - Phone:912-980-7342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA183500000X363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant