| NPI | 1255789392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PAX000012566) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9109462) |
| Enumeration Date | 2016-05-31 |
| Last Update Date | 2016-09-29 |