| NPI | 1114129749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 003547) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9116801) | |
| Enumeration Date | 2007-06-05 |
| Last Update Date | 2025-02-14 |