| NPI | 1306486196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9116945) |
| Enumeration Date | 2020-01-09 |
| Last Update Date | 2025-12-18 |