| NPI | 1578622957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IA 129689) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA 9102147) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2025-04-14 |