=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992698781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANG-WILLIAMS MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2025
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7927 STATE ROAD 52
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-6783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-863-5808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12191 W LINEBAUGH AVE STE 607
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33626-1732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-334-6134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MRS. SHERISSA CHANG-WILLIAMS
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 813-334-6134
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------