| NPI | 1972563658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA 3582) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 005275-1) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA07448) | |
| Enumeration Date | 2006-03-25 |
| Last Update Date | 2015-03-22 |