| NPI | 1134491244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106412) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK PA751) |
| Enumeration Date | 2012-02-04 |
| Last Update Date | 2012-02-04 |