| NPI | 1780050666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108973) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7215) |
| Enumeration Date | 2015-08-14 |
| Last Update Date | 2024-02-07 |