Provider Demographics
NPI:1508072331
Name:FOFANA, KERFALA (PA-C)
Entity Type:Individual
Prefix:
First Name:KERFALA
Middle Name:
Last Name:FOFANA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:KERFALA
Other - Middle Name:
Other - Last Name:FOFANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:500 WINDERLEY PL STE 115
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7406
Mailing Address - Country:US
Mailing Address - Phone:407-875-0555
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL STE 115
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7406
Practice Address - Country:US
Practice Address - Phone:407-875-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9105531363AM0700X
OH50.007046RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant