| NPI | 1407378011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118027) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2024-11-13 |