| NPI | 1982103396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113302) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 55108) |
| Enumeration Date | 2018-02-12 |
| Last Update Date | 2023-02-21 |