| NPI | 1982643425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00519) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA0002048) |
| Enumeration Date | 2006-06-06 |
| Last Update Date | 2016-03-21 |