| NPI | 1477615862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 006320) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9102549) |
| Enumeration Date | 2006-12-14 |
| Last Update Date | 2011-12-19 |