| NPI | 1801961156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9104288) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: GA 03671) |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2021-03-07 |