| NPI | 1316040694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108536) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA02140) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-01089) | |
| Enumeration Date | 2006-09-05 |
| Last Update Date | 2017-02-24 |