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Provider Information for 1154803435

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1154803435

Calendar   Last Updated:  2018-09-03
  Certification Date: 


Name Value
NPI 1154803435
Enumeration Date 2018-09-03
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 4003 HUDSON TER
TAMPA, FL 33618-5348
United States

Phone: 786-370-9079 | Fax:
View Map External Link
Primary Practice Address 4816 N ARMENIA AVE
TAMPA, FL 33603-1400
United States

Phone: 813-876-3636 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
MEDICAID FL $$$$$$$$$
Primary Taxonomy Selected Taxonomy State License Number
Yes 363LF0000X - Nurse Practitioner Family FL 9435711