Provider Demographics
NPI:1407322308
Name:KORNBLUM, GENEVIEVE (PA-C)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:KORNBLUM
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 1:1001 NW 13TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2269
Mailing Address - Country:US
Mailing Address - Phone:561-955-6663
Mailing Address - Fax:561-995-2879
Practice Address - Street 1:2800 S SEACREST BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7966
Practice Address - Country:US
Practice Address - Phone:561-736-8200
Practice Address - Fax:561-736-4635
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111722363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical