| NPI | 1629502463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9119021) |
| Additional Taxonomies | 247200000X Technician, Other (Licence: PR 008557) |
| Enumeration Date | 2017-04-19 |
| Last Update Date | 2024-07-24 |