| NPI | 1679198048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117795) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 1682) |
| Enumeration Date | 2020-06-11 |
| Last Update Date | 2023-11-24 |