| NPI | 1679519300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA3244) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601011648) |
| 363A00000X Physician Assistant (Licence: KY PA3179) | |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2024-07-30 |