| NPI | 1235331349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9112974) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-07735) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2007-06-01 |
| Last Update Date | 2024-02-07 |