| NPI | 1043672249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116004) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5651) |
| Enumeration Date | 2016-03-25 |
| Last Update Date | 2024-09-09 |