| NPI | 1700995354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103004) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003768) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2008-06-11 |