Provider Demographics
NPI:1659021145
Name:CULIQI, GEIRSA
Entity Type:Individual
Prefix:
First Name:GEIRSA
Middle Name:
Last Name:CULIQI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 MANDARIN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7831
Mailing Address - Country:US
Mailing Address - Phone:904-502-8866
Mailing Address - Fax:
Practice Address - Street 1:10870 US ONE N UNIT 104
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32081-7804
Practice Address - Country:US
Practice Address - Phone:904-438-2720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-27
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FL9116452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program