Healthcare Provider Details

I. General information

NPI: 1518964238
Provider Name (Legal Business Name): DAVID WAYNE RUNYON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 SE 17TH ST
OCALA FL
34471-5519
US

IV. Provider business mailing address

2750 SE 17TH ST
OCALA FL
34471-5519
US

V. Phone/Fax

Practice location:
  • Phone: 352-732-7779
  • Fax: 352-732-2664
Mailing address:
  • Phone: 352-732-7779
  • Fax: 352-732-2664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number838
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA9109546
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: