| NPI | 1801239223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107218) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001500A) |
| 363A00000X Physician Assistant (Licence: KY PA1821) | |
| Enumeration Date | 2013-04-16 |
| Last Update Date | 2023-05-15 |