| NPI | 1538164298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9100695) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-01113) |
| Enumeration Date | 2005-06-17 |
| Last Update Date | 2015-10-22 |