| NPI | 1639698699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110813) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2017-09-11 |
| Last Update Date | 2019-03-05 |