Healthcare Provider Details

I. General information

NPI: 1437628260
Provider Name (Legal Business Name): DON ANTON DAYANTHA WISIDAGAMA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2018
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 RODEL CV
LAKE MARY FL
32746-4859
US

IV. Provider business mailing address

725 RODEL CV
LAKE MARY FL
32746-4859
US

V. Phone/Fax

Practice location:
  • Phone: 407-302-3130
  • Fax: 407-302-3132
Mailing address:
  • Phone: 407-302-3130
  • Fax: 407-302-3132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113883
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: