| NPI | 1619418977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2017012740) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110144) |
| Enumeration Date | 2017-03-19 |
| Last Update Date | 2022-09-15 |