| 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 |