| NPI | 1508300187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115298) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA058623) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2016-12-15 |
| Last Update Date | 2022-04-08 |