Provider Demographics
NPI:1225122468
Name:WOODIWISS, GARY DONALD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DONALD
Last Name:WOODIWISS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13403 BOYETTE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8742
Mailing Address - Country:US
Mailing Address - Phone:813-654-1775
Mailing Address - Fax:813-651-9082
Practice Address - Street 1:13403 BOYETTE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-8742
Practice Address - Country:US
Practice Address - Phone:813-654-1775
Practice Address - Fax:813-651-9082
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL91-03542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ58832Medicare UPIN
FLU6588ZMedicare PIN