Individual
DOR MORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
300 PINELLAS ST, CLEARWATER, FL 33756-3804
(727) 462-7000
Mailing address
300 PINELLAS ST, CLEARWATER, FL 33756-3804
(727) 298-6612
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
12608
GA
363A00000X
Physician Assistant
Primary
PA9120086
FL
Other
Enumeration date
08/27/2024
Last updated
05/19/2026
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