| NPI | 1902839921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 5605) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 9102639) |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2017-01-06 |