Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | ME123703 | FL |
NPI | 1003010349 |
---|---|
Provider Name | Dr. Wissam M Shaya |
First Address | Fort Myers, FL 33901-9342 |
Second Address | Jacksonville, FL 32257-6013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2007 |
Last Update Date | 23/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
015772000 | (05) | FL |
NY876 | MEDICARE (01) | FL |