Provider Demographics
NPI:1275397622
Name:THAWALANTHANNE, SAN
Entity Type:Individual
Prefix:
First Name:SAN
Middle Name:
Last Name:THAWALANTHANNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-4415
Mailing Address - Country:US
Mailing Address - Phone:815-451-2897
Mailing Address - Fax:
Practice Address - Street 1:106 W WINDHORST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2455
Practice Address - Country:US
Practice Address - Phone:813-373-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty