| NPI | 1730915141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9119248) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2024-09-11 |
| Last Update Date | 2025-02-03 |