| NPI | 1801286927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA91085200) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9108520) |
| Enumeration Date | 2015-01-27 |
| Last Update Date | 2022-02-15 |