| NPI | 1710915996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2350) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9105544) |
| 363A00000X Physician Assistant (Licence: TN 1368) | |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2021-04-28 |