| NPI | 1053863746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9109426) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 97201) |
| Enumeration Date | 2016-10-27 |
| Last Update Date | 2022-04-13 |