1588796767 NPI number — DANA J. KILLMAN PA-C

Table of content: DANA J. KILLMAN PA-C (NPI 1588796767)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588796767 NPI number — DANA J. KILLMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLMAN
Provider First Name:
DANA
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1588796767
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3240 S FLORIDA AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33803-4574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-644-7337
Provider Business Mailing Address Fax Number:
863-904-0398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 POPE AVE NW
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33881-4679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-299-2630
Provider Business Practice Location Address Fax Number:
863-969-0723
Provider Enumeration Date:
03/12/2007

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: 363A00000X , with the licence number:  PA734 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9108494 , 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: 95002994 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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