| NPI | 1144692898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06880) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 4816) |
| 363A00000X Physician Assistant (Licence: FL TPPA946) | |
| Enumeration Date | 2015-10-21 |
| Last Update Date | 2025-07-30 |