| NPI | 1073506614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110033) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000626) |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2017-01-12 |