| NPI | 1457608796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 6892) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106671) |
| Enumeration Date | 2012-08-06 |
| Last Update Date | 2016-09-28 |