| NPI | 1184709503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 12413) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AR PA-1078) |
| 363A00000X Physician Assistant (Licence: NY 0011335) | |
| 363A00000X Physician Assistant (Licence: FL PA9109622) | |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2024-07-22 |