Healthcare Provider Details

I. General information

NPI: 1730092057
Provider Name (Legal Business Name): DAT LE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 FRANKFORD AVE APT 4103
PANAMA CITY FL
32405-1945
US

IV. Provider business mailing address

3625 FRANKFORD AVE APT 4103
PANAMA CITY FL
32405-1945
US

V. Phone/Fax

Practice location:
  • Phone: 813-291-1331
  • Fax:
Mailing address:
  • Phone: 813-291-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberWDL4S8N3B23B
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: