Provider Demographics
NPI:1538521596
Name:DANG WYNN MEDICAL
Entity type:Organization
Organization Name:DANG WYNN MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-960-1200
Mailing Address - Street 1:5332 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4829
Mailing Address - Country:US
Mailing Address - Phone:813-960-1200
Mailing Address - Fax:813-441-7555
Practice Address - Street 1:5332 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4829
Practice Address - Country:US
Practice Address - Phone:813-960-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-28
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty