Provider Demographics
NPI:1356920227
Name:SEIDMAN, DALLAS ELLEN
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:ELLEN
Last Name:SEIDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 MURFREESBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37210-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 COUNTY ROAD 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-633-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant