| NPI | 1467451203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 100443) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA3125) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA3125) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA3125) | |
| 363AM0700X Physician Assistant, Medical (Licence: NC 100443) | |
| Enumeration Date | 2005-07-14 |
| Last Update Date | 2012-11-27 |