| NPI | 1851623136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115279) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11595) |
| Enumeration Date | 2010-02-11 |
| Last Update Date | 2022-09-21 |