Provider Demographics
NPI:1922096460
Name:MEDAN, DAU'WD B (PA)
Entity Type:Individual
Prefix:
First Name:DAU'WD
Middle Name:B
Last Name:MEDAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4962 SWEET CEDAR CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8106
Mailing Address - Country:US
Mailing Address - Phone:407-381-0546
Mailing Address - Fax:
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101976363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S40979Medicare UPIN
FLE7659WMedicare ID - Type Unspecified