| NPI | 1285478644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118823) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-06-20 |
| Last Update Date | 2024-09-11 |