| NPI | 1487628376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10229) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101447) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2022-04-04 |