| NPI | 1245342385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WY 370) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9102593) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2008-09-25 |