NPI | 1740479104 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9101120) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AL PA251) |
363AM0700X Physician Assistant, Medical (Licence: AZ 3801) | |
Enumeration Date | 2007-10-22 |
Last Update Date | 2008-12-12 |