MEDICARE: GEIRSA CULIQI

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	390200000X	Student in an Organized Health Care Education/Training Program		FL
2	363A00000X	Physician Assistant	9116452	FL

General Provider Information

NPI Number	:	1659021145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEIRSA CULIQI

Provider Business Mailing Address
First Line	:	3375 MANDARIN GLEN DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-7831
Country	:	US
Telephone Number	:	904-502-8866
Fax Number	:

Provider Business Practice Location Address
First Line	:	10870 US ONE N UNIT 104
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32081-7804
Country	:	US
Telephone Number	:	904-438-2720
Fax Number	:

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

Provider Enumeration Date	:	03/27/2022
Last Update Date	:	09/28/2022

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