| NPI | 1912533076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117464) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 024865) |
| Enumeration Date | 2020-03-19 |
| Last Update Date | 2023-10-30 |