| NPI | 1730625443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110124) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PAT 9110124) |
| Enumeration Date | 2017-01-19 |
| Last Update Date | 2019-04-24 |