Provider Demographics
NPI:1952340861
Name:BOTTOM, WAYNE D (PA C)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:D
Last Name:BOTTOM
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:D
Other - Last Name:BOTTOME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-7955
Practice Address - Fax:352-265-7996
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67825Medicare UPIN
E1621ZMedicare PIN