| NPI | 1013744051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9119590) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0009619) |
| Enumeration Date | 2024-09-16 |
| Last Update Date | 2025-02-14 |