| NPI | 1245677103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-08700) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9107242) | |
| Enumeration Date | 2013-05-31 |
| Last Update Date | 2022-01-04 |