| NPI | 1710858972 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9120769) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9120769) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9120769) | |
| Enumeration Date | 2025-09-12 |
| Last Update Date | 2025-12-16 |