| NPI | 1194823781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9121105) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01174) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2025-12-02 |