| NPI | 1316286651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9113415) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 1714) |
| Enumeration Date | 2013-02-06 |
| Last Update Date | 2020-12-28 |