| NPI | 1265625313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110199) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-004665) |
| Enumeration Date | 2007-08-22 |
| Last Update Date | 2023-08-16 |