| NPI | 1992375554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116218) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-008149) |
| Enumeration Date | 2021-06-28 |
| Last Update Date | 2024-01-16 |