Provider Demographics
NPI:1578817649
Name:STATPA-C INC
Entity Type:Organization
Organization Name:STATPA-C INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:813-802-9969
Mailing Address - Street 1:5604 GLEN CREST BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-1001
Mailing Address - Country:US
Mailing Address - Phone:813-802-9969
Mailing Address - Fax:
Practice Address - Street 1:5604 GLEN CREST BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-1001
Practice Address - Country:US
Practice Address - Phone:813-802-9969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9100648363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP41434Medicare UPIN