| NPI | 1295724920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA3597) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03520) |
| Enumeration Date | 2005-10-15 |
| Last Update Date | 2013-01-03 |