| NPI | 1033628326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111816) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA-1279) |
| Enumeration Date | 2017-09-29 |
| Last Update Date | 2020-08-19 |