NPI | 1679519300 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA3244) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601011648) |
363A00000X Physician Assistant (Licence: KY PA3179) | |
Enumeration Date | 2006-06-21 |
Last Update Date | 2024-07-30 |