| NPI | 1649670779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PAT9108094) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05688) |
| Enumeration Date | 2014-08-26 |
| Last Update Date | 2015-05-28 |