| NPI | 1053617985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL pa9105715) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-02804) |
| Enumeration Date | 2011-02-10 |
| Last Update Date | 2016-04-04 |