| NPI | 1144260746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL 9104154) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 565) |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2012-06-11 |