| NPI | 1407956360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1307) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA2857) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2007-07-08 |