Basic Information
| Provider Information | |||||||||
| NPI: | 1437395324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOKLOSA | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 S HARBOR CITY BLVD STE 610 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217237716 | ||||||||
| FaxNumber: | 3217230604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 S HARBOR CITY BLVD STE 610 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217237716 | ||||||||
| FaxNumber: | 3217230604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 01/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9105437 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 022305300 | 05 | FL | MEDICAID | Y00U9 | 01 | FL | FLORIDA BLUE | OTHER |