Healthcare Provider Details

I. General information

NPI: 1588932727
Provider Name (Legal Business Name): PHAYLINH WELLS SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHAYLINH WELLS PA-C

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 WALDEMERE ST SUITE 504
SARASOTA FL
34239-2943
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-1579
  • Fax: 941-917-4340
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106345
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: