| NPI | 1760671200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 4501) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9104392) |
| Enumeration Date | 2007-10-22 |
| Last Update Date | 2017-03-08 |