| NPI | 1700055068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA 9104519) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022142) |
| Enumeration Date | 2008-02-20 |
| Last Update Date | 2019-03-15 |