Provider Demographics
NPI:1396216529
Name:PAPA, DYLAN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:CHRISTOPHER
Last Name:PAPA
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 1:2200 DOULTON DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-8408
Mailing Address - Country:US
Mailing Address - Phone:860-836-1318
Mailing Address - Fax:
Practice Address - Street 1:2501 N ORANGE AVE STE 340
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4601
Practice Address - Country:US
Practice Address - Phone:407-895-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9112199OtherFLORIDA PA LICENSE