| NPI | 1104301332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111676) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: FL PA911676) |
| Enumeration Date | 2018-10-03 |
| Last Update Date | 2018-10-31 |