Provider Demographics
NPI:1912498130
Name:MOHIUDDIN, AFFAN (PA-C)
Entity Type:Individual
Prefix:
First Name:AFFAN
Middle Name:
Last Name:MOHIUDDIN
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 1:12830 WOODBURY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-5925
Mailing Address - Country:US
Mailing Address - Phone:407-923-1069
Mailing Address - Fax:
Practice Address - Street 1:8132 LEE VISTA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32829-8367
Practice Address - Country:US
Practice Address - Phone:407-807-6522
Practice Address - Fax:407-988-1922
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT4137363AM0700X
FLPA9113282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical