| NPI | 1962549097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA3291) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA3291) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA3291) | |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2011-03-15 |