Healthcare Provider Details

I. General information

NPI: 1487802054
Provider Name (Legal Business Name): TROY A WUBBENA PA-C, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 SHADE AVE STE 108
SARASOTA FL
34243-2878
US

IV. Provider business mailing address

8451 SHADE AVE STE 108
SARASOTA FL
34243-2878
US

V. Phone/Fax

Practice location:
  • Phone: 941-360-1030
  • Fax: 941-360-1202
Mailing address:
  • Phone: 941-360-1030
  • Fax: 941-360-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9104389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: