| NPI | 1871897009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106499) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PAT9105709) |
| Enumeration Date | 2011-01-03 |
| Last Update Date | 2020-10-15 |