Provider Demographics
NPI:1740804673
Name:WIN, BRIAN (PA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:WIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:KYAW
Other - Middle Name:SWA
Other - Last Name:WIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3019
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:130 PABLO ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3818
Practice Address - Country:US
Practice Address - Phone:863-284-6800
Practice Address - Fax:863-687-1033
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113319363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical