| NPI | 1023295664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 1659) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9104565) |
| 363AM0700X Physician Assistant, Medical (Licence: CO 2517) | |
| Enumeration Date | 2008-01-25 |
| Last Update Date | 2010-01-14 |