| NPI | 1821538653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA110201) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA9110201) |
| Enumeration Date | 2017-02-27 |
| Last Update Date | 2021-09-16 |