| NPI | 1477095164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2719) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110014) |
| Enumeration Date | 2016-11-10 |
| Last Update Date | 2019-03-18 |