| NPI | 1689701708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10370) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 010250) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9104423) | |
| Enumeration Date | 2007-02-27 |
| Last Update Date | 2021-08-16 |