| NPI | 1144934589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117435) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: OK 4971) | |
| Enumeration Date | 2023-01-10 |
| Last Update Date | 2026-02-12 |