| NPI | 1710075957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9102469) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 9102469) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2014-07-01 |