| NPI | 1609289651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113261) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 11280) |
| 363A00000X Physician Assistant (Licence: WY PT808) | |
| 363A00000X Physician Assistant (Licence: PA MA056844) | |
| Enumeration Date | 2014-06-07 |
| Last Update Date | 2023-03-24 |