Provider Demographics
NPI:1962047670
Name:KISGEROPOULOS, ANNAMARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANNAMARIE
Middle Name:
Last Name:KISGEROPOULOS
Suffix:
Gender:F
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 1:6213 WOODHAVEN VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6850
Mailing Address - Country:US
Mailing Address - Phone:386-341-0652
Mailing Address - Fax:
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 206
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:407-384-7388
Practice Address - Fax:407-384-1140
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2025-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112758208C00000X
FLPA9112758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery