| NPI | 1245213594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9102792) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AL PA421) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2016-03-15 |