| NPI | 1679844575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9106228) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 1679844575) |
| 363A00000X Physician Assistant (Licence: PA MA056823) | |
| Enumeration Date | 2012-01-24 |
| Last Update Date | 2023-08-17 |