| NPI | 1366041402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115478) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA 324554) |
| Enumeration Date | 2020-10-20 |
| Last Update Date | 2022-12-23 |