| NPI | 1104804210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9102400) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA91024) |
| Enumeration Date | 2006-01-09 |
| Last Update Date | 2017-12-12 |