| NPI | 1235657412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111996) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 9214) |
| 363A00000X Physician Assistant (Licence: HI AMD1246) | |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2024-03-18 |