Provider Demographics
NPI:1992750038
Name:BROWN, DAVID WIDLUND (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WIDLUND
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 CENTERVILLE RD STE 5000
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4663
Mailing Address - Country:US
Mailing Address - Phone:850-877-7886
Mailing Address - Fax:850-877-0738
Practice Address - Street 1:1405 CENTERVILLE RD
Practice Address - Street 2:SUITE 5000
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4655
Practice Address - Country:US
Practice Address - Phone:850-877-7886
Practice Address - Fax:850-877-0738
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0001631363AS0400X
GA3931363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS87081Medicare UPIN
FLE2880ZMedicare ID - Type Unspecified
GA97WCDDRMedicare ID - Type Unspecified