| NPI | 1275717191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117637) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1070431) |
| Enumeration Date | 2007-12-27 |
| Last Update Date | 2026-06-02 |