| NPI | 1861649816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03999) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: FL PA 9104608) | |
| Enumeration Date | 2008-08-21 |
| Last Update Date | 2024-12-18 |