Healthcare Provider Details

I. General information

NPI: 1962238394
Provider Name (Legal Business Name): WILLIAM R CUNNINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 TOWN CENTER DR
ORANGE CITY FL
32763-8360
US

IV. Provider business mailing address

1075 TOWN CENTER DR
ORANGE CITY FL
32763-8360
US

V. Phone/Fax

Practice location:
  • Phone: 386-917-0333
  • Fax: 386-917-0335
Mailing address:
  • Phone: 386-917-0333
  • Fax: 386-917-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9119284
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: