| NPI | 1275962706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114436) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA172423) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9107632) | |
| Enumeration Date | 2013-11-05 |
| Last Update Date | 2022-08-26 |