Provider Demographics
NPI:1750490629
Name:KOONTZ, LORALEE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LORALEE
Middle Name:
Last Name:KOONTZ
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 1:2605 W. SWANN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4039
Mailing Address - Country:US
Mailing Address - Phone:813-872-9551
Mailing Address - Fax:813-872-9554
Practice Address - Street 1:2605 W. SWANN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4039
Practice Address - Country:US
Practice Address - Phone:813-872-9551
Practice Address - Fax:813-872-9554
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291750500Medicaid
FL291750500Medicaid
FLE4795ZMedicare ID - Type Unspecified