Provider Demographics
NPI:1649208596
Name:KNOWLES, BILLY MACK (PA)
Entity Type:Individual
Prefix:MR
First Name:BILLY
Middle Name:MACK
Last Name:KNOWLES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-0242
Mailing Address - Country:US
Mailing Address - Phone:813-654-2445
Mailing Address - Fax:813-654-9885
Practice Address - Street 1:500 VONDERBURG DR
Practice Address - Street 2:SUITE 311 WEST
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5964
Practice Address - Country:US
Practice Address - Phone:813-654-2445
Practice Address - Fax:813-654-9885
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1479ZMedicare UPIN
Q00553Medicare UPIN