| NPI | 1487024329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 2561) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 2018-00571) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9109012) | |
| Enumeration Date | 2015-10-05 |
| Last Update Date | 2019-05-30 |