1780010512 NPI number — YANINA ABAUNZA-FIALLOS MD PA

Table of content: (NPI 1780010512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780010512 NPI number — YANINA ABAUNZA-FIALLOS MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YANINA ABAUNZA-FIALLOS MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1780010512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17541 N. DALE MABRY HWY.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-964-1800
Provider Business Mailing Address Fax Number:
813-964-1880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17541 N. DALE MABRY HWY.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUTZ
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-964-1800
Provider Business Practice Location Address Fax Number:
813-964-1880
Provider Enumeration Date:
09/25/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PANDIAN
Authorized Official First Name:
GOWTHAM
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
813-964-1800

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME69011 , 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: 115642600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com