| NPI | 1588774905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA 9101337) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101337) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2025-03-14 |