| NPI | 1679628556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108485) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: 1073878) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2016-05-31 |