| NPI | 1336653740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110838) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA067397) |
| Enumeration Date | 2017-11-21 |
| Last Update Date | 2025-12-22 |