Healthcare Provider Details

I. General information

NPI: 1154143592
Provider Name (Legal Business Name): YANINA ABAUNZA-FIALLOS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 PROFESSIONAL PARK DR
BRANDON FL
33511-4886
US

IV. Provider business mailing address

17541 N DALE MABRY HWY
LUTZ FL
33548-4521
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-5659
  • Fax: 813-685-2640
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: GOWTHAMAN PANDIAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 813-964-1800