| NPI | 1154617009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116266) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA pa4195) |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2024-03-13 |