| NPI | 1083211486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113755) |
| 363A00000X Physician Assistant (Licence: AZ 8956) | |
| Enumeration Date | 2020-10-08 |
| Last Update Date | 2024-10-15 |