Provider Demographics
NPI:1750546040
Name:HERTZOG, KRISTINE C (PA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:C
Last Name:HERTZOG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:C
Other - Last Name:POYNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7725 MILLBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7812
Mailing Address - Country:US
Mailing Address - Phone:407-408-4355
Mailing Address - Fax:
Practice Address - Street 1:805 CENTURY MEDICAL DR STE A
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2100
Practice Address - Country:US
Practice Address - Phone:321-567-7530
Practice Address - Fax:321-225-8723
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104652363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant