Provider Demographics
NPI:1619209889
Name:WOODALL, WILLIAM SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SHANE
Last Name:WOODALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 VENETIAN WAY
Mailing Address - Street 2:94
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-8806
Mailing Address - Country:US
Mailing Address - Phone:305-989-1135
Mailing Address - Fax:
Practice Address - Street 1:305 S ANDREWS AVE
Practice Address - Street 2:601
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-1859
Practice Address - Country:US
Practice Address - Phone:954-767-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9104825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical