| NPI | 1538819818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9696) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 1237) |
| 363A00000X Physician Assistant (Licence: FL TPPA338) | |
| Enumeration Date | 2022-03-28 |
| Last Update Date | 2025-02-27 |