| NPI | 1790123743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06304) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA 9107230) |
| Enumeration Date | 2013-06-12 |
| Last Update Date | 2019-03-14 |