| NPI | 1770139388 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114291) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA13816) |
| Enumeration Date | 2019-08-11 |
| Last Update Date | 2021-09-16 |