| NPI | 1194720417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110-004254) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9102298) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2014-02-19 |