| NPI | 1851743504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN96) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 10098) |
| Enumeration Date | 2016-07-06 |
| Last Update Date | 2025-11-25 |