| NPI | 1669751293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114261) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014992) |
| Enumeration Date | 2011-08-13 |
| Last Update Date | 2021-08-13 |