| NPI | 1104177039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: DE C5-0001051) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9106867) |
| Enumeration Date | 2012-10-02 |
| Last Update Date | 2020-09-14 |