| NPI | 1134107352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840579) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106607) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2019-02-13 |