| NPI | 1831506518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108749) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05125) |
| Enumeration Date | 2014-07-15 |
| Last Update Date | 2015-10-07 |