| NPI | 1366956229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9119492) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08949) |
| Enumeration Date | 2017-11-29 |
| Last Update Date | 2025-10-28 |