Provider Demographics
NPI:1225275647
Name:EVERETT, WARREN UMANDAP (PA)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:UMANDAP
Last Name:EVERETT
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 1:14813 TANJA KING BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828
Mailing Address - Country:US
Mailing Address - Phone:443-254-3377
Mailing Address - Fax:
Practice Address - Street 1:607 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2603
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03597363A00000X
NJ25MP00738600363AM0700X
MAPA9508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical