=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760212989
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMAD Q MOHYUDDIN AA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2024
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2616 ANTIETAM TRL
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32312-4841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-241-5868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 339 CONSORT DR
-----------------------------------------------------
City | BALLWIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-4439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-386-9224
-----------------------------------------------------
Fax | 636-386-7679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | PENDING
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | AA1055
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------