| NPI | 1376026518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113243) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08439) |
| Enumeration Date | 2018-09-13 |
| Last Update Date | 2025-03-12 |