| NPI | 1154307353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103207) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL 9103207) |
| Enumeration Date | 2005-12-20 |
| Last Update Date | 2009-11-06 |