| NPI | 1245485424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110411) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 005534) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2008-12-01 |
| Last Update Date | 2019-07-16 |