| NPI | 1407518442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9115161) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9115161) |
| Enumeration Date | 2021-10-07 |
| Last Update Date | 2025-03-03 |