| NPI | 1073081816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118466) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 4497) |
| Enumeration Date | 2018-11-09 |
| Last Update Date | 2025-10-06 |