| NPI | 1396516480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PACN16) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PR 2018) |
| Enumeration Date | 2024-01-09 |
| Last Update Date | 2025-08-09 |