| NPI | 1699261206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9111357) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9111357) |
| Enumeration Date | 2018-07-06 |
| Last Update Date | 2020-01-27 |