| NPI | 1710526447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114240) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09664) |
| Enumeration Date | 2019-12-28 |
| Last Update Date | 2021-06-17 |