| NPI | 1164405114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA3516) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA 484) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PAX00002031) | |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2018-04-25 |