Individual
DAT VU
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3625 UNIVERSITY BLVD S, JACKSONVILLE, FL 32216-4207
(904) 399-6111
Mailing address
3518 BRANDYWINE RD NW, KENNESAW, GA 30144-6060
(404) 406-3730
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
8171
GA
367H00000X
Anesthesiologist Assistant
Primary
AA447
FL
367H00000X
Anesthesiologist Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8171
STATE OF GEORGIA MEDICAL BOARD
GA
01
—
AA447
STATE OF FL DEPARTMENT OF HEALTH
FL
Enumeration date
09/02/2016
Last updated
04/25/2018
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