1609866219 NPI number — MR. WARREN RANDALL SUMNER PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609866219 NPI number — MR. WARREN RANDALL SUMNER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUMNER
Provider First Name:
WARREN
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609866219
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10744
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33757-8744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-532-0002
Provider Business Mailing Address Fax Number:
727-266-4943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 W DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
MAB 2ND FLOOR
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-321-6580
Provider Business Practice Location Address Fax Number:
813-443-8185
Provider Enumeration Date:
10/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  003541 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 003541 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA9108734 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 404215 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 015768600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100001160D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01067693 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00679501 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0155PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113420300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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