| NPI | 1639664535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111400) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-06-25 |
| Last Update Date | 2019-06-05 |