| NPI | 1164875738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9624) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109654) |
| Enumeration Date | 2016-07-19 |
| Last Update Date | 2020-03-17 |