| NPI | 1255321972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-00482) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9102207) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2007-07-08 |