Provider Demographics
NPI:1790750388
Name:KORFHAGE, LIZAMAR S (PA C)
Entity Type:Individual
Prefix:
First Name:LIZAMAR
Middle Name:S
Last Name:KORFHAGE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:LIZAMAR
Other - Middle Name:DELOURDES
Other - Last Name:SULSONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5619
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:205 E NASA BLVD FL 2
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1950
Practice Address - Country:US
Practice Address - Phone:321-361-5619
Practice Address - Fax:321-728-4135
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7845WOtherMEDICARE
FL100869800Medicaid
FLE7845XMedicare PIN