| NPI | 1477071108 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112207) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-07532) |
| Enumeration Date | 2017-09-01 |
| Last Update Date | 2024-12-31 |