| NPI | 1548756893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MO 2018024459) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA9111443) |
| Enumeration Date | 2018-07-10 |
| Last Update Date | 2021-09-15 |