Provider Demographics
NPI:1023115813
Name:LONSDORFER, KIMMAI MAGALI (PA)
Entity type:Individual
Prefix:
First Name:KIMMAI
Middle Name:MAGALI
Last Name:LONSDORFER
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 1:1849 WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3980
Mailing Address - Country:US
Mailing Address - Phone:407-463-0193
Mailing Address - Fax:
Practice Address - Street 1:968 W MITCHELL HAMMOCK RD STE 1050
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8123
Practice Address - Country:US
Practice Address - Phone:407-890-1890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4409ZMedicare ID - Type Unspecified
FLP11307Medicare UPIN