| NPI | 1861820599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107280) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA16601) |
| 363A00000X Physician Assistant (Licence: CO PA.0007710) | |
| 363A00000X Physician Assistant (Licence: WA PA61396487) | |
| Enumeration Date | 2013-10-15 |
| Last Update Date | 2025-01-06 |