| NPI | 1316486111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9116729) |
| Additional Taxonomies | 405300000X Prevention Professional (Licence: FL AL4728) |
| Enumeration Date | 2017-02-14 |
| Last Update Date | 2023-07-13 |