| NPI | 1699009118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106680) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9106680) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60115659) | |
| Enumeration Date | 2009-09-30 |
| Last Update Date | 2021-03-30 |