Individual
MR. JACOB LEE WONDERLICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
40100 HIGHWAY 27, DAVENPORT, FL 33837
(863) 422-4971
Mailing address
8390 CHAMPIONS GATE BOULEVARD, SUITE 306, CHAMPIONS GATE, FL 33896
(407) 390-1677
(407) 390-1765
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA9103414
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
292248700
—
FL
Enumeration date
08/21/2006
Last updated
07/07/2021
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