| NPI | 1104195957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107090) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA21807) |
| Enumeration Date | 2011-12-23 |
| Last Update Date | 2026-02-09 |