Provider Demographics
NPI:1588796767
Name:KILLMAN, DANA J (PA-C)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:J
Last Name:KILLMAN
Suffix:
Gender:F
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 1:3240 S FLORIDA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4574
Mailing Address - Country:US
Mailing Address - Phone:863-644-7337
Mailing Address - Fax:863-904-0398
Practice Address - Street 1:550 POPE AVE NW
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4679
Practice Address - Country:US
Practice Address - Phone:863-299-2630
Practice Address - Fax:863-969-0723
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA734363A00000X
FLPA9108494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002994Medicaid
1881785947OtherGROUP NPI NUMBER
KY6824OtherMEDICARE GROUP ID
KYP00908426OtherRAILROAD MEDICARE INDIVIDUAL ID # KY
KYCH6639OtherGROUP RAILROAD MEDICARE
KY7100112830OtherKY MEDICAID PA GROUP #
000000632378OtherANTHEM INDIVIDUAL ID#
KY0682422Medicare PIN
KY50025072OtherPASSPORT INDIVIDUAL ID #
KY95002994Medicaid