Healthcare Provider Details

I. General information

NPI: 1609866219
Provider Name (Legal Business Name): WARREN RANDALL SUMNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 W DR MARTIN LUTHER KING JR BLVD MAB 2ND FLOOR
TAMPA FL
33607-6307
US

IV. Provider business mailing address

PO BOX 10744
CLEARWATER FL
33757-8744
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-6580
  • Fax: 813-443-8185
Mailing address:
  • Phone: 727-532-0002
  • Fax: 727-266-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003541
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003541
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9108734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: