Basic Information
| Provider Information | |||||||||
| NPI: | 1821286170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASADI-FRAZIER | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRAZIER ANTONELLI | ||||||||
| OtherFirstName: | CORY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750412 | ||||||||
| FaxNumber: | 4079750413 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079750412 | ||||||||
| FaxNumber: | 4079750413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 12/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704300463 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | RN-296830/NP-07044 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | APRN11000729 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2340416 | 05 | OH | MEDICAID |