| NPI | 1336579374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9107633) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107633) |
| Enumeration Date | 2013-11-12 |
| Last Update Date | 2018-10-19 |