| NPI | 1215762133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN94) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 002361) |
| Enumeration Date | 2024-09-03 |
| Last Update Date | 2025-08-20 |