| NPI | 1821768524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9114963) |
| Enumeration Date | 2021-09-15 |
| Last Update Date | 2021-12-03 |