| NPI | 1023194750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103819) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA12718) |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2009-03-05 |