Basic Information
Provider Information
NPI: 1003010349
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHAYA
FirstName: WISSAM
MiddleName: M
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1907 ATLANTIC BLVD
Address2:  
City: JACKSONVILLE
State: FL
PostalCode: 322073466
CountryCode: US
TelephoneNumber: 9043884712
FaxNumber:  
Practice Location
Address1: 1907 ATLANTIC BLVD
Address2:  
City: JACKSONVILLE
State: FL
PostalCode: 322073466
CountryCode: US
TelephoneNumber: 9043884712
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/12/2007
LastUpdateDate: 06/09/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X4301082473MIY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
430108247301MISTATE LICENSEOTHER


Home