| NPI | 1386949204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9109155) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT 26044) |
| Enumeration Date | 2011-01-25 |
| Last Update Date | 2016-10-18 |