| NPI | 1013555796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112654) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA3042) |
| Enumeration Date | 2019-12-13 |
| Last Update Date | 2026-07-10 |