| NPI | 1194765321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114520) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA003004L) |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2022-07-01 |