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Provider Information for 1326017757

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: 1326017757

Calendar   Last Updated:  2019-07-12
  Certification Date: 


Name Value
NPI 1326017757
Enumeration Date 2006-03-17
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 14690 SPRING HILL DR STE 305
SPRING HILL, FL 34609-8102
United States

Phone: 352-277-5348 | Fax: 352-606-2857
View Map External Link
Primary Practice Address 6279 N LECANTO HWY
BEVERLY HILLS, FL 34465-2503
United States

Phone: 352-522-0094 | Fax: 352-522-0098
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Other TRI CARE FL 59-3682760
MEDICAID FL 000694000
Primary Taxonomy Selected Taxonomy State License Number
Yes 363A00000X - Physician Assistant FL PA 9104143