Provider Demographics
NPI:1245096502
Name:CORSACK, LIUDA
Entity type:Individual
Prefix:
First Name:LIUDA
Middle Name:
Last Name:CORSACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18136 NW 61ST PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33015
Mailing Address - Country:US
Mailing Address - Phone:786-290-2471
Mailing Address - Fax:
Practice Address - Street 1:18136 NW 61ST PL
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33015
Practice Address - Country:US
Practice Address - Phone:786-290-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024620363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner