| 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 |