| NPI | 1316566136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14448) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9114933) |
| Enumeration Date | 2020-04-11 |
| Last Update Date | 2025-01-31 |