| NPI | 1184274862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14197) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103766) |
| Enumeration Date | 2019-09-16 |
| Last Update Date | 2024-05-23 |