| NPI | 1659399400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9101072) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.A10345.RX) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2024-08-05 |