| NPI | 1164436655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9107955) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110009501) |
| 363A00000X Physician Assistant (Licence: MI 5601012124) | |
| 363AM0700X Physician Assistant, Medical (Licence: GA 002061) | |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA063830) | |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2024-10-16 |