| NPI | 1174188544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007202) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 8224) |
| 363A00000X Physician Assistant (Licence: FL PA9112732) | |
| 363A00000X Physician Assistant (Licence: GA 9635) | |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2025-01-10 |