Provider Demographics
NPI:1538782321
Name:KOERBER, ALLYSSA NICOLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:ALLYSSA
Middle Name:NICOLE
Last Name:KOERBER
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 1:3953 S NOVA RD STE B
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4910
Mailing Address - Country:US
Mailing Address - Phone:386-788-4911
Mailing Address - Fax:844-388-6186
Practice Address - Street 1:3953 S NOVA RD STE B
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4910
Practice Address - Country:US
Practice Address - Phone:386-788-4911
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 390200000X
FLPA9115064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program