| NPI | 1194186510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114495) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC464) |
| Enumeration Date | 2016-03-12 |
| Last Update Date | 2023-06-13 |