Basic Information
Provider Information | |||||||||
NPI: | 1619209889 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOODALL | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | SHANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 35 VENETIAN WAY | ||||||||
Address2: | 94 | ||||||||
City: | MIAMI BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 331398806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3059891135 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 305 S ANDREWS AVE | ||||||||
Address2: | 601 | ||||||||
City: | FT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333011859 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9547670273 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2010 | ||||||||
LastUpdateDate: | 06/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9104825 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.