| NPI | 1124294947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105417) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 9105417) |
| Enumeration Date | 2008-05-01 |
| Last Update Date | 2023-08-07 |