Healthcare Provider Details

I. General information

NPI: 1285719476
Provider Name (Legal Business Name): LIZA MARSHALL KRUHM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S ORLANDO AVE SUITE 200
WINTER PARK FL
32789-7109
US

IV. Provider business mailing address

951 BROKEN SOUND PKWY NW SUITE 225
BOCA RATON FL
33487-3507
US

V. Phone/Fax

Practice location:
  • Phone: 407-622-5766
  • Fax: 407-622-5767
Mailing address:
  • Phone: 561-241-9300
  • Fax: 561-372-0214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9103730
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: