| NPI | 1144766452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111115) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06916) |
| Enumeration Date | 2017-01-10 |
| Last Update Date | 2022-12-23 |