| NPI | 1225631203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PACN13) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 863-PA) |
| Enumeration Date | 2020-11-20 |
| Last Update Date | 2025-03-21 |