| NPI | 1467603134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA 9108566) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012244) |
| Enumeration Date | 2008-09-30 |
| Last Update Date | 2022-01-27 |