| NPI | 1144642315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113024) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 1115670) |
| Enumeration Date | 2014-01-07 |
| Last Update Date | 2020-09-30 |