| NPI | 1467876615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AR PA-536) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: AR 1635) |
| 363A00000X Physician Assistant (Licence: FL PA9110930) | |
| Enumeration Date | 2014-02-08 |
| Last Update Date | 2022-09-16 |