| 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 |