| NPI | 1700976966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL pa9100463) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 2156522) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2011-08-29 |