| NPI | 1669018701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112641) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| Enumeration Date | 2019-11-25 |
| Last Update Date | 2021-02-15 |