| NPI | 1518996024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08118) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA3144) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2018-08-11 |