| NPI | 1659339844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001011979) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA.9104640) |
| 363A00000X Physician Assistant (Licence: SC 430) | |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2022-02-10 |