Provider Demographics
NPI:1124403704
Name:DAVID, SHADIN (PA)
Entity Type:Individual
Prefix:
First Name:SHADIN
Middle Name:
Last Name:DAVID
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 S DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7817
Mailing Address - Country:US
Mailing Address - Phone:813-234-0100
Mailing Address - Fax:813-234-0115
Practice Address - Street 1:2700 HEALING WAY STE 300
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5453
Practice Address - Country:US
Practice Address - Phone:813-333-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108802363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015398600Medicaid