Provider Demographics
NPI:1073397998
Name:DEWITT, CODY WALLACE (PA)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:WALLACE
Last Name:DEWITT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 49TH ST N APT 1-306
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-5275
Mailing Address - Country:US
Mailing Address - Phone:701-425-1036
Mailing Address - Fax:
Practice Address - Street 1:201 14TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3133
Practice Address - Country:US
Practice Address - Phone:727-588-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117778363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical