| NPI | 1053698266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0008879) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA09183) |
| 363A00000X Physician Assistant (Licence: FL PA9106331) | |
| Enumeration Date | 2011-11-16 |
| Last Update Date | 2024-11-04 |