| NPI | 1124454558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108236) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2460) |
| Enumeration Date | 2013-09-17 |
| Last Update Date | 2022-07-21 |