| NPI | 1770654576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112209) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 002225) |
| Enumeration Date | 2006-11-13 |
| Last Update Date | 2020-01-20 |