| NPI | 1568920593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113895) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: TN 3860) | |
| 363A00000X Physician Assistant (Licence: GA 9366) | |
| Enumeration Date | 2019-03-08 |
| Last Update Date | 2022-09-18 |