Provider Demographics
NPI:1316336076
Name:EDGAR, CORY MICAL (PA-C)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:MICAL
Last Name:EDGAR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 N ORANGE AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5558
Mailing Address - Country:US
Mailing Address - Phone:407-303-2070
Mailing Address - Fax:407-303-2071
Practice Address - Street 1:2415 N ORANGE AVE STE 601
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5558
Practice Address - Country:US
Practice Address - Phone:407-303-2070
Practice Address - Fax:407-303-2071
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
TXPA09629363A00000X
FLPA9109621363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant