Healthcare Provider Details

I. General information

NPI: 1306477666
Provider Name (Legal Business Name): LAURA MEGAN GWILLIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 07/21/2022
Certification Date: 07/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15415 PLANTATION OAKS DR APT 3
TAMPA FL
33647-2152
US

IV. Provider business mailing address

2502 W SAINT ISABEL ST
TAMPA FL
33607-6318
US

V. Phone/Fax

Practice location:
  • Phone: 941-374-0457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116051
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: