| NPI | 1780936278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106930) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9106930) |
| Enumeration Date | 2012-10-08 |
| Last Update Date | 2025-12-16 |