| NPI | 1912500109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113850) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PAX000017679) |
| Enumeration Date | 2020-11-19 |
| Last Update Date | 2023-01-30 |