| NPI | 1780641621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: LA PA.A10295) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 102694) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9112036) | |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2020-10-21 |