| NPI | 1861820243 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05145) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107554) |
| Enumeration Date | 2013-10-23 |
| Last Update Date | 2014-11-18 |