| NPI | 1275843906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA060617) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110172) |
| 363AM0700X Physician Assistant Medical (Licence: TX PA 02489) | |
| 363A00000X Physician Assistant (Licence: SC 1636) | |
| Enumeration Date | 2010-10-15 |
| Last Update Date | 2020-12-23 |