| NPI | 1750478608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110399) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 007156) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2021-12-29 |