| NPI | 1912275066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05682) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 9106301) |
| Enumeration Date | 2011-12-05 |
| Last Update Date | 2015-08-06 |