| NPI | 1366535296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA 2769) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12921) |
| 363A00000X Physician Assistant (Licence: CA 53408) | |
| 363A00000X Physician Assistant (Licence: WA 60999946) | |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2025-03-06 |