| NPI | 1164016663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PAT9117647) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9117647) |
| Enumeration Date | 2021-02-24 |
| Last Update Date | 2024-11-18 |