| NPI | 1871538272 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103294) |
| Additional Taxonomies | 174400000X Specialist (Licence: FL PA9103294) |
| Enumeration Date | 2006-06-19 |
| Last Update Date | 2018-04-05 |