| NPI | 1225024680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL pa9104118) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 1863) |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2012-06-07 |