| NPI | 1568885077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111766) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 5606) |
| Enumeration Date | 2014-02-04 |
| Last Update Date | 2020-11-17 |