| NPI | 1144022633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN105) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 2501) |
| Enumeration Date | 2025-03-25 |
| Last Update Date | 2025-10-21 |