| NPI | 1518009612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9110559) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 3652) |
| 363AM0700X Physician Assistant, Medical (Licence: GA 3652) | |
| 363AS0400X Physician Assistant, Surgical (Licence: GA 3652) | |
| Enumeration Date | 2007-02-13 |
| Last Update Date | 2020-09-15 |