| NPI | 1457178071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN69) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 2307-P.A.) |
| Enumeration Date | 2024-09-24 |
| Last Update Date | 2025-07-16 |