| NPI | 1518956200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9102944) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA680) |
| Enumeration Date | 2005-10-17 |
| Last Update Date | 2012-09-11 |