| NPI | 1497586630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9120239) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 13567) |
| Enumeration Date | 2024-08-09 |
| Last Update Date | 2025-11-19 |