| NPI | 1801648621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118746) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA66190) |
| 363A00000X Physician Assistant (Licence: VA 0110010390) | |
| Enumeration Date | 2024-04-04 |
| Last Update Date | 2025-04-05 |