Basic Information
| Provider Information | |||||||||
| NPI: | 1508462060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWAFFORD | ||||||||
| FirstName: | SAVANNAH | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 919379 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328919379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444531406 | ||||||||
| FaxNumber: | 7726213180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 7TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278251100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2020 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1181427 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | NL814 | 01 | FL | FL MEDICARE | OTHER | AYCEQ | 01 | FL | FL BCBS | OTHER | 109746100 | 05 | FL | MEDICAID | Q0053081 | 01 | FL | FL RAILROAD MEDICARE | OTHER |