| NPI | 1578873535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9116370) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9116370) |
| Enumeration Date | 2010-10-08 |
| Last Update Date | 2025-05-23 |