| NPI | 1689048068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010471) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109185) |
| Enumeration Date | 2015-11-23 |
| Last Update Date | 2024-12-17 |