| NPI | 1750924916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112605) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: FL PA9112605) |
| Enumeration Date | 2019-10-21 |
| Last Update Date | 2020-07-17 |