| NPI | 1922799964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117590) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC033) |
| Enumeration Date | 2023-05-19 |
| Last Update Date | 2025-09-18 |