| NPI | 1104252618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107487) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PAT9107487) |
| Enumeration Date | 2013-09-17 |
| Last Update Date | 2021-09-14 |