| NPI | 1104891654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA 9105729) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 1414) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA 9105729) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9105729) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9105729) | |
| Enumeration Date | 2006-02-20 |
| Last Update Date | 2022-04-14 |