| NPI | 1699060160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105986) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PAT9105986) |
| Enumeration Date | 2011-06-13 |
| Last Update Date | 2019-08-07 |