| NPI | 1649285230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103553) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103394) |
| Enumeration Date | 2006-07-30 |
| Last Update Date | 2024-06-18 |