Healthcare Provider Details

I. General information

NPI: 1346222569
Provider Name (Legal Business Name): FLOR MARITZA LLISO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5795 CARRIAGE HILLS DR
AUGUSTA GA
30907-8208
US

IV. Provider business mailing address

5795 CARRIAGE HILLS DR
AUGUSTA GA
30907-8208
US

V. Phone/Fax

Practice location:
  • Phone: 912-980-7342
  • Fax:
Mailing address:
  • Phone: 912-980-7342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number183500000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: