| NPI | 1407410772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9121051) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: FL PTA25948) |
| Enumeration Date | 2019-04-23 |
| Last Update Date | 2025-12-03 |