| NPI | 1154570331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105009) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA053587) |
| Enumeration Date | 2008-09-12 |
| Last Update Date | 2023-06-29 |