| NPI | 1306525829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN2) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL TPPA556) |
| 363AM0700X Physician Assistant, Medical (Licence: PR 1753-PA) | |
| 363A00000X Physician Assistant (Licence: AZ 10358) | |
| Enumeration Date | 2023-07-12 |
| Last Update Date | 2026-01-15 |