| NPI | 1689933343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106529) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9106529) |
| Enumeration Date | 2012-05-15 |
| Last Update Date | 2024-09-27 |