Provider Demographics
NPI:1013660851
Name:MOOGERFELD, CORY ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:ADAM
Last Name:MOOGERFELD
Suffix:
Gender:M
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 1:17900 WAYSIDE BND
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33982-5056
Mailing Address - Country:US
Mailing Address - Phone:954-579-6657
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115334363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical