| NPI | 1780652974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107926) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 544) |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2016-08-16 |