Basic Information
| Provider Information | |||||||||
| NPI: | 1740804673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WIN | ||||||||
| OtherFirstName: | KYAW | ||||||||
| OtherMiddleName: | SWA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338053019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636807000 | ||||||||
| FaxNumber: | 8662648519 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 PABLO ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338033818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632846800 | ||||||||
| FaxNumber: | 8636871033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2020 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9113319 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.