| NPI | 1881020147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08409) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9107497) |
| Enumeration Date | 2013-09-18 |
| Last Update Date | 2018-11-06 |