Provider Demographics
NPI:1073503975
Name:PAUL, JOHN WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:PAUL
Suffix:
Gender:M
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 1:6410 S MACDILL AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-5022
Mailing Address - Country:US
Mailing Address - Phone:813-827-9870
Mailing Address - Fax:
Practice Address - Street 1:6410 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-5022
Practice Address - Country:US
Practice Address - Phone:813-827-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2009-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1043024OtherNCCPA BOARD CERTIFICATION
FLU3830ZOtherMEDICARE NUMBER