| NPI | 1164749719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2003002306) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101165) |
| Enumeration Date | 2010-04-22 |
| Last Update Date | 2010-04-22 |