Provider Demographics
NPI:1760212989
Name:MOHYUDDIN, MOHAMMAD Q (AA)
Entity type:Individual
Prefix:MR
First Name:MOHAMMAD
Middle Name:Q
Last Name:MOHYUDDIN
Suffix:
Gender:
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 CONSORT DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4439
Mailing Address - Country:US
Mailing Address - Phone:636-386-9224
Mailing Address - Fax:636-386-7679
Practice Address - Street 1:2616 ANTIETAM TRL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-4841
Practice Address - Country:US
Practice Address - Phone:850-241-5868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPENDING367H00000X
FLAA1055367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant