MEDICARE: MS. KRISTINE ROBERTA ILGENFRITZ PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9100962	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144382623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTINE ROBERTA ILGENFRITZ PAC

Provider Business Mailing Address
First Line	:	109 TIMBERLACHEN CIR
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3395
Country	:	US
Telephone Number	:	407-333-9877
Fax Number	:	407-333-9881

Provider Business Practice Location Address
First Line	:	109 TIMBERLACHEN CIR
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3395
Country	:	US
Telephone Number	:	407-333-9877
Fax Number	:	407-333-9881

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/18/2021

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