| NPI | 1912261793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08367) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106601) |
| Enumeration Date | 2012-06-27 |
| Last Update Date | 2022-08-30 |