| NPI | 1487479150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9119632) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL 9119632) |
| Enumeration Date | 2024-11-18 |
| Last Update Date | 2025-02-11 |