| NPI | 1255893046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113545) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0010-008908) |
| 363A00000X Physician Assistant (Licence: NY 026793) | |
| 363A00000X Physician Assistant (Licence: IL 085009720) | |
| 363A00000X Physician Assistant (Licence: CA 58581) | |
| Enumeration Date | 2019-04-02 |
| Last Update Date | 2024-06-13 |