| NPI | 1679113567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116085) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061426) |
| Enumeration Date | 2020-01-09 |
| Last Update Date | 2022-07-18 |