| NPI | 1972037760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PACN47) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL 24250) |
| 363A00000X Physician Assistant (Licence: PR 302-P.A.) | |
| Enumeration Date | 2017-04-18 |
| Last Update Date | 2025-05-10 |