| NPI | 1073561171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106977) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1040) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2012-12-28 |