| NPI | 1871992016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9109924) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 007279) |
| Enumeration Date | 2014-08-13 |
| Last Update Date | 2020-04-23 |