Basic Information
| Provider Information | |||||||||
| NPI: | 1609866219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMNER | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664943 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | MAB 2ND FLOOR | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133216580 | ||||||||
| FaxNumber: | 8134438185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 003541 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 003541 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA9108734 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 404215 | 01 | GA | WELLCARE | OTHER | 015768600 | 05 | FL | MEDICAID | 100001160D | 05 | GA | MEDICAID | 01067693 | 01 | GA | AMERIGROUP | OTHER | P00679501 | 01 | GA | RR MEDICARE | OTHER | 0155PA | 05 | SC | MEDICAID |