| NPI | 1689069932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA5696) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA 9108624) |
| Enumeration Date | 2015-04-03 |
| Last Update Date | 2017-01-20 |