| NPI | 1407554702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN43) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 1563) |
| Enumeration Date | 2023-02-16 |
| Last Update Date | 2025-05-02 |