| NPI | 1902235443 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9115238) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1102022) |
| Enumeration Date | 2013-11-05 |
| Last Update Date | 2026-05-20 |