| NPI | 1942802095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114221) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-007536) |
| Enumeration Date | 2020-11-13 |
| Last Update Date | 2023-09-23 |