| NPI | 1467050120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12221) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113585) |
| Enumeration Date | 2020-10-15 |
| Last Update Date | 2023-10-05 |