| NPI | 1487634168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103742) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 004074) |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2018-03-17 |