| NPI | 1780253831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN26) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 8810) |
| Enumeration Date | 2021-06-23 |
| Last Update Date | 2025-04-09 |