| NPI | 1447551346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9105904) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0004202) |
| 363A00000X Physician Assistant (Licence: PA MA000302L) | |
| Enumeration Date | 2010-11-09 |
| Last Update Date | 2015-01-27 |