| NPI | 1255697421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106477) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005360) |
| Enumeration Date | 2012-04-02 |
| Last Update Date | 2020-11-16 |