Provider Demographics
NPI: | 1629527643 |
---|---|
Name: | TRAYA, WESLEY (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | WESLEY |
Middle Name: | |
Last Name: | TRAYA |
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: | 1400 S ORANGE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | ORLANDO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32806-2134 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 407-648-3800 |
Mailing Address - Fax: | 407-425-5203 |
Practice Address - Street 1: | 5673 PEACHTREE DUNWOODY RD STE 350 |
Practice Address - Street 2: | |
Practice Address - City: | ATLANTA |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30342 |
Practice Address - Country: | US |
Practice Address - Phone: | 404-778-3712 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-10-03 |
Last Update Date: | 2018-08-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PA9109886 | 363AM0700X |
GA | 8771 | 363AS0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 018993000 | Medicaid | |
FL | 018993000 | Medicaid |