NPI | 1164242277 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PACN66) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL TPPA800) |
363A00000X Physician Assistant (Licence: PR 2180PA) | |
Enumeration Date | 2024-10-14 |
Last Update Date | 2025-07-31 |