| NPI | 1457004012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115801) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 2034) |
| Enumeration Date | 2022-02-02 |
| Last Update Date | 2022-08-26 |