| NPI | 1639618408 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07125) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9110061) |
| Enumeration Date | 2017-02-14 |
| Last Update Date | 2024-01-29 |