| NPI | 1013211937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105842) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 022420) |
| Enumeration Date | 2011-01-06 |
| Last Update Date | 2020-08-19 |