| NPI | 1346480159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04537) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107094) |
| Enumeration Date | 2009-03-06 |
| Last Update Date | 2013-11-04 |