| NPI | 1851475776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117176) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 57357) |
| 363A00000X Physician Assistant (Licence: IL 085.002843) | |
| 363A00000X Physician Assistant (Licence: NY 019136) | |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2023-07-11 |