| NPI | 1043559461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110859) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 006713) |
| Enumeration Date | 2013-02-05 |
| Last Update Date | 2018-03-17 |