| NPI | 1538678248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10430) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110602) |
| Enumeration Date | 2017-09-26 |
| Last Update Date | 2024-11-13 |