| NPI | 1851800874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110665) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000010119) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-09-21 |
| Last Update Date | 2024-11-08 |