| NPI | 1881295525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9113763) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113763) |
| Enumeration Date | 2020-11-07 |
| Last Update Date | 2021-01-08 |