| NPI | 1184055121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107548) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL Pat9107548) |
| Enumeration Date | 2013-12-02 |
| Last Update Date | 2023-07-19 |