| NPI | 1629322706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9106950) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106950) |
| Enumeration Date | 2012-10-29 |
| Last Update Date | 2018-04-24 |