| NPI | 1497718274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 101617) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 2009) |
| Enumeration Date | 2006-04-11 |
| Last Update Date | 2013-01-22 |