Provider Demographics
NPI:1992926703
Name:KORTREY, RICHARD A (PA-AA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:KORTREY
Suffix:
Gender:M
Credentials:PA-AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:866-507-5244
Practice Address - Fax:855-851-4405
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2343367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000476AOtherPEACHSTATE CMO - MCCG
GA100000476AMedicaid
GA344347OtherWELLCARE CMO - MCCG
GA430052725OtherRAILROAD MCR - MCCG
GA344347OtherWELLCARE CMO - MCCG
GA430052725OtherRAILROAD MCR - MCCG