| NPI | 1447926316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024013598) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9114962) |
| Enumeration Date | 2021-08-19 |
| Last Update Date | 2024-09-16 |