| NPI | 1588093611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107644) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA9107644) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2013-11-08 |
| Last Update Date | 2022-12-28 |