| NPI | 1922593367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9111308) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08068) |
| Enumeration Date | 2018-06-28 |
| Last Update Date | 2018-10-04 |