| NPI | 1205879624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9102685) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 006719) |
| 363A00000X Physician Assistant (Licence: PA MA051752) | |
| 363A00000X Physician Assistant (Licence: VA 0110001906) | |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2007-07-08 |