| NPI | 1659077634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117141) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9117041) |
| Enumeration Date | 2023-02-01 |
| Last Update Date | 2023-08-30 |