| NPI | 1437523099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114099) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06174) |
| Enumeration Date | 2015-11-19 |
| Last Update Date | 2022-11-01 |