NPI | 1316699481 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115603) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 19415) |
363A00000X Physician Assistant (Licence: FL 9115603) | |
Enumeration Date | 2022-01-20 |
Last Update Date | 2022-08-11 |