| NPI | 1760436513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 005699) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103659) |
| Enumeration Date | 2006-05-19 |
| Last Update Date | 2022-01-10 |