| NPI | 1205075777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110231) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06274) |
| 363A00000X Physician Assistant (Licence: GA 5482) | |
| 363A00000X Physician Assistant (Licence: SC 3426) | |
| Enumeration Date | 2009-02-06 |
| Last Update Date | 2020-12-29 |