| NPI | 1679169783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116491) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA101520) |
| 363A00000X Physician Assistant (Licence: GA 010232) | |
| 363A00000X Physician Assistant (Licence: AZ 11007) | |
| Enumeration Date | 2020-12-14 |
| Last Update Date | 2025-03-31 |