| NPI | 1215499090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9113599) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113599) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-02 |
| Last Update Date | 2022-09-26 |