| NPI | 1639408644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115195) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0003228) |
| Enumeration Date | 2009-12-22 |
| Last Update Date | 2022-11-03 |