| NPI | 1730620410 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 008291) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9114730) |
| Enumeration Date | 2017-03-15 |
| Last Update Date | 2022-09-02 |