| NPI | 1912913468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9103773) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005528) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2020-09-24 |