| NPI | 1407859077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13142) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 001072) |
| 363A00000X Physician Assistant (Licence: FL PA2336) | |
| Enumeration Date | 2005-05-27 |
| Last Update Date | 2023-03-24 |