| NPI | 1043582489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115345) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2114) |
| 363A00000X Physician Assistant (Licence: WI 8222) | |
| Enumeration Date | 2012-02-01 |
| Last Update Date | 2025-07-21 |