| NPI | 1023129806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9109340) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA-001195-L) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2023-05-19 |