| NPI | 1972140093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11833) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA061306) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9113948) | |
| Enumeration Date | 2019-12-09 |
| Last Update Date | 2024-05-01 |