Facts
- Status
- A
- Credential
- PA
- Type
- Individual
- Enumeration date
- 2005-08-31
- Last updated
- 2015-04-23
Specialties
Licenses
- License FL
- PA3292
Location
- Practice location
- 812 W INDIAN BLVD.
- City
- EDGEWATER FL
- Postal code
- 321323429
- Phone
- 386-426-1411
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.